Basic Information
| Provider Information | |||||||||
| NPI: | 1639686520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDE | ||||||||
| FirstName: | MYRA | ||||||||
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| Credential: | CRNA | ||||||||
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| OtherLastName: | HETH | ||||||||
| OtherFirstName: | MYRA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2801 46TH AVE SE APT 3 | ||||||||
| Address2: | |||||||||
| City: | MANDAN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585544795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015908198 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1440 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056444000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2018 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R39280 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.