Healthcare Provider Details

I. General information

NPI: 1922545896
Provider Name (Legal Business Name): PAUL EDWARD RUTTLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 TRADER RD
JACKSON WY
83001-8321
US

IV. Provider business mailing address

PO BOX 7471
JACKSON WY
83002-7471
US

V. Phone/Fax

Practice location:
  • Phone: 307-413-6677
  • Fax:
Mailing address:
  • Phone: 307-413-6677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3415A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: