Healthcare Provider Details

I. General information

NPI: 1316953433
Provider Name (Legal Business Name): HEATHER M RUDISILL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 TALBOT RD S STE 401
RENTON WA
98055-5738
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 425-656-4224
  • Fax: 425-656-5099
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00040152
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: