Basic Information
| Provider Information | |||||||||
| NPI: | 1174283584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDISILL | ||||||||
| FirstName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SKYLINE VILLAGE LOOP S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973069490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033911110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5050 SKYLINE VILLAGE LOOP S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973069490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033911110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2021 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 202114701NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.