Healthcare Provider Details

I. General information

NPI: 1730254996
Provider Name (Legal Business Name): HAYDEE RUDHOLM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 ZONAL AVE
LOS ANGELES CA
90033-1065
US

IV. Provider business mailing address

5935 PLAYA VISTA DR APT 102
PLAYA VISTA CA
90094-2131
US

V. Phone/Fax

Practice location:
  • Phone: 323-223-6146
  • Fax: 323-223-6399
Mailing address:
  • Phone: 323-841-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 13119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: