Basic Information
| Provider Information | |||||||||
| NPI: | 1245621168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIDER | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742616 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702198420 | ||||||||
| FaxNumber: | 7702198440 | ||||||||
| Practice Location | |||||||||
| Address1: | 743 SPRING ST NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702192627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2015 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN102391 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LC0200X | RN102391 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.