Basic Information
| Provider Information | |||||||||
| NPI: | 1275563363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAUDERDALE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50 | ||||||||
| Address2: | |||||||||
| City: | OAKES | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584740050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017423267 | ||||||||
| FaxNumber: | 7017423201 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 SOUTH 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | OAKES | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584742024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017423267 | ||||||||
| FaxNumber: | 7017423201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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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 | 363AM0700X | PAC0054 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | CF8850 | 01 | ND | RAILROAD MEDICARE | OTHER | 18895 | 01 | ND | BLUE SHIELD | OTHER |