Provider Demographics
NPI:1033480140
Name:RUEDISUELI, TRACY R (PA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:RUEDISUELI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 WOODMAN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1400
Mailing Address - Country:US
Mailing Address - Phone:937-424-2215
Mailing Address - Fax:937-252-1224
Practice Address - Street 1:1010 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1400
Practice Address - Country:US
Practice Address - Phone:937-424-2215
Practice Address - Fax:937-252-1224
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003411363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH067080Medicare PIN