Basic Information
| Provider Information | |||||||||
| NPI: | 1851342034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUTKOWSKI | ||||||||
| FirstName: | DEBRA | ||||||||
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| Credential: | MS, APRN, BC-FNP, CD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | UNITED HEALTH SERVICES HOSP INC | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077700025 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 ARCH ST | ||||||||
| Address2: | DIABETES EDUCATION AND MANAGEMENT CENTER | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636092 | ||||||||
| FaxNumber: | 6077636677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 11/04/2008 | ||||||||
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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 | 363LF0000X | F333913-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02672099 | 05 | NY | MEDICAID |