Healthcare Provider Details

I. General information

NPI: 1891070744
Provider Name (Legal Business Name): ANGELA MARIE REDDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E 7TH ST
POWELL WY
82435-2126
US

IV. Provider business mailing address

1201 E 7TH ST
POWELL WY
82435-2126
US

V. Phone/Fax

Practice location:
  • Phone: 307-764-4107
  • Fax:
Mailing address:
  • Phone: 307-764-4107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMED-PAC-LIC-51041
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number531
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTL531
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: