Healthcare Provider Details

I. General information

NPI: 1730966334
Provider Name (Legal Business Name): RILEY KUDERCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4757 E WINSETT ST
TUCSON AZ
85711-4370
US

IV. Provider business mailing address

1701 E 10TH ST
TUCSON AZ
85719-5917
US

V. Phone/Fax

Practice location:
  • Phone: 520-232-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number286057
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: