Healthcare Provider Details

I. General information

NPI: 1811213127
Provider Name (Legal Business Name): TARA MARIE RUUD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 MAYFAIR AVE MESABA CLINICS- FAIRVIEW
HIBBING MN
55746-2935
US

IV. Provider business mailing address

3605 MAYFAIR AVE MESABA CLINICS- FAIRVIEW
HIBBING MN
55746-2935
US

V. Phone/Fax

Practice location:
  • Phone: 218-262-3441
  • Fax:
Mailing address:
  • Phone: 218-262-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: