Provider Demographics
NPI:1538528658
Name:RAYDER, ALICIA E (NP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:E
Last Name:RAYDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:E
Other - Last Name:VELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5008 BRITTONFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9248
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-634-4677
Practice Address - Street 1:5008 BRITTONFIELD PKWY
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-634-4677
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339773363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400301925Medicare PIN