Healthcare Provider Details

I. General information

NPI: 1366738874
Provider Name (Legal Business Name): PAETRA JANE RUDDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19917 7TH AVE NE STE 203
POULSBO WA
98370-6555
US

IV. Provider business mailing address

1793 13TH ST SE
SALEM OR
97302-2541
US

V. Phone/Fax

Practice location:
  • Phone: 360-824-5474
  • Fax: 360-994-4975
Mailing address:
  • Phone: 503-362-8385
  • Fax: 503-362-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2015026116
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD61231855
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: