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General NPI Number Information
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NPI Number | 1164544193
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Entity Type | Individual
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Provider Name | MICHAEL RUCKER
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Gender | Male
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 10/11/2023
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Provider Practice Location Address
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Address Line | 2415 N ORANGE AVE STE 700
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City | ORLANDO
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State | FL
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Zip | 32804-5521
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Country | US
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Telephone | 407-303-2474
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Fax |
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Provider Business Mailing Address
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Address Line | 4584 OLD CARRIAGE TRL
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City | OVIEDO
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State | FL
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Zip | 32765-8473
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Country | US
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Telephone | 407-701-4253
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Fax | 407-679-4343
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA2204
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License Number State | FL
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