Healthcare Provider Details

I. General information

NPI: 1063407013
Provider Name (Legal Business Name): THOMAS RUFFALO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 SUMMIT AVE
OCONOMOWOC WI
53066-3844
US

IV. Provider business mailing address

541 S SAWYER RD
OCONOMOWOC WI
53066-9243
US

V. Phone/Fax

Practice location:
  • Phone: 262-569-9119
  • Fax:
Mailing address:
  • Phone: 262-244-7693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number657-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: