Provider Demographics
NPI:1891070744
Name:REDDER, ANGELA MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:REDDER
Suffix:
Gender:F
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 1:1201 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2126
Mailing Address - Country:US
Mailing Address - Phone:307-764-4107
Mailing Address - Fax:
Practice Address - Street 1:1201 E 7TH ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2126
Practice Address - Country:US
Practice Address - Phone:307-764-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL531363A00000X
MTMED-PAC-LIC-51041363AM0700X
WY531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY531OtherWYOMING LICENSE
WYTL531OtherTEMPORARY LICENSE NUMBER