MEDICARE: CRYSTAL D RUCKER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	461	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699873257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL D RUCKER PA-C

Provider Business Mailing Address
First Line	:	PO BOX 35
Second Line	:
City	:	NEWBURG
State	:	WV
Zip	:	26410-0035
Country	:	US
Telephone Number	:	304-892-2828
Fax Number	:	304-892-2927

Provider Business Practice Location Address
First Line	:	725 N PIKE ST
Second Line	:
City	:	GRAFTON
State	:	WV
Zip	:	26354-1270
Country	:	US
Telephone Number	:	304-265-4909
Fax Number	:	304-265-4915

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	02/25/2019

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