Provider Demographics
NPI:1205041241
Name:RUDD, TERRA D (PA)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:D
Last Name:RUDD
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 1:100 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-1435
Mailing Address - Country:US
Mailing Address - Phone:410-778-7668
Mailing Address - Fax:410-810-7186
Practice Address - Street 1:100 BROWN ST
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1435
Practice Address - Country:US
Practice Address - Phone:410-778-7668
Practice Address - Fax:410-810-7186
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0649363A00000X
NC0010-01645363AM0700X
MDC0005108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0649OtherLICENSE
NC0010-01645OtherSTATE MEDICAL LICENSE
MDC0005108OtherPHYSICIAN ASSISTANT STATE LICENSE