Basic Information
| Provider Information | |||||||||
| NPI: | 1780936419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRYDER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PAXTON | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3077547217 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3077547217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2012 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 23690.1217 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.