Provider Demographics
NPI:1194884494
Name:RIDER, JERRY (PA-C)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:RIDER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10TH MEDICAL GROUP/SGHC
Mailing Address - Street 2:4102 PINION DR
Mailing Address - City:AIR FORCE ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840
Mailing Address - Country:US
Mailing Address - Phone:719-684-3159
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-2361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X
TN2594363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical