Basic Information
| Provider Information | |||||||||
| NPI: | 1750615654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRIDER | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 W CRESCENT PARK | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147233300 | ||||||||
| FaxNumber: | 8147238952 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 PLEASANT DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163653371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147263310 | ||||||||
| FaxNumber: | 8147231338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2009 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2875 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA058967 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 80988580 | 05 | CO | MEDICAID |