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General NPI Number Information
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NPI Number | 1366738874
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Entity Type | Individual
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Provider Name | PAETRA JANE RUDDY MD
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Gender | Female
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Dates
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Enumeration Date | 06/22/2011
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Last Update Date | 10/15/2024
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Provider Practice Location Address
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Address Line | 19917 7TH AVE NE STE 203
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City | POULSBO
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State | WA
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Zip | 98370-6555
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Country | US
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Telephone | 360-824-5474
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Fax | 360-994-4975
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Provider Business Mailing Address
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Address Line | 1793 13TH ST SE
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City | SALEM
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State | OR
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Zip | 97302-2541
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Country | US
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Telephone | 503-362-8385
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Fax | 503-362-8435
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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 | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 2015026116
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | MD61231855
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License Number State | WA
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