MEDICARE: MR. GARY RUESCH NP

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	363LP0200X	Pediatric Nurse Practitioner	200595-4405	UT

General Provider Information

NPI Number	:	1851381628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY RUESCH NP

Provider Business Mailing Address
First Line	:	7321 11TH ST
Second Line	:	HILL AFB
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84056-5012
Country	:	US
Telephone Number	:	801-777-7109
Fax Number	:	801-775-3039

Provider Business Practice Location Address
First Line	:	7321 11TH ST
Second Line	:	HILL AFB
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84056-5012
Country	:	US
Telephone Number	:	801-777-7109
Fax Number	:	801-775-3039

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	07/08/2007

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