Healthcare Provider Details

I. General information

NPI: 1609265065
Provider Name (Legal Business Name): RUDOLPH PAVLESICH III DNP, CRNA, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 05/17/2020
Certification Date: 05/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 HOSPITAL RD
PLYMOUTH NH
03264-1126
US

IV. Provider business mailing address

89 STEVENS HILL RD
NOTTINGHAM NH
03290-4802
US

V. Phone/Fax

Practice location:
  • Phone: 603-536-1120
  • Fax:
Mailing address:
  • Phone: 904-535-1875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017019797
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number281215
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9178468
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number074985-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: