Healthcare Provider Details

I. General information

NPI: 1922425735
Provider Name (Legal Business Name): ELIZABETH MARIE RUDOLPHI PA AS OF 3/28/14
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE PRESBYTERIAN KASEMAN FAMILY MEDICINE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2402
  • Fax:
Mailing address:
  • Phone: 505-291-2402
  • 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: