1083919682 NPI number — MISS ELAINE CATHERINE KISER-RUDE PA-C

Table of content: MISS ELAINE CATHERINE KISER-RUDE PA-C (NPI 1083919682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083919682 NPI number — MISS ELAINE CATHERINE KISER-RUDE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KISER-RUDE
Provider First Name:
ELAINE
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KISER
Provider Other First Name:
ELAINE
Provider Other Middle Name:
CATHERIN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083919682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 S J ST FL 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-274-7505
Provider Business Mailing Address Fax Number:
360-830-1385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1608 S J ST FL 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-274-7505
Provider Business Practice Location Address Fax Number:
360-830-1385
Provider Enumeration Date:
01/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA60798305 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OA5114 . This is a "GROUP MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2108176 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com