Basic Information
| Provider Information | |||||||||
| NPI: | 1871643304 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUTAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | RN, APN, C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 MIDSUMMER DR | ||||||||
| Address2: | |||||||||
| City: | OLD BRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088572712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326070223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 BERGEN ST | ||||||||
| Address2: | SUITE 7100 | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739722400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 26NC08521200 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 8382905 | 05 | NJ | MEDICAID |