Healthcare Provider Details

I. General information

NPI: 1104312834
Provider Name (Legal Business Name): NICHOLAS LEE RUDOLPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6515 BARRIE RD STE 100
EDINA MN
55435-2364
US

IV. Provider business mailing address

320 22ND AVE NE
WASECA MN
56093-2670
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-5019
  • Fax:
Mailing address:
  • Phone: 507-461-1998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11207
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: