Provider Demographics
NPI:1275563363
Name:LAUDERDALE, RICHARD R (PAC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:R
Last Name:LAUDERDALE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:OAKES
Mailing Address - State:ND
Mailing Address - Zip Code:58474-0050
Mailing Address - Country:US
Mailing Address - Phone:701-742-3267
Mailing Address - Fax:701-742-3201
Practice Address - Street 1:420 SOUTH 7TH STREET
Practice Address - Street 2:
Practice Address - City:OAKES
Practice Address - State:ND
Practice Address - Zip Code:58474-2024
Practice Address - Country:US
Practice Address - Phone:701-742-3267
Practice Address - Fax:701-742-3201
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0054363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDCF8850OtherRAILROAD MEDICARE
ND18895OtherBLUE SHIELD
NDCF8850OtherRAILROAD MEDICARE
NDS24178Medicare UPIN
NDN18895Medicare Oscar/Certification
NDCF8850Medicare PIN