Provider Demographics
NPI:1407307135
Name:EPPERSON, RUTH
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:EPPERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HARPST ST
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-8222
Mailing Address - Country:US
Mailing Address - Phone:707-826-3146
Mailing Address - Fax:
Practice Address - Street 1:1 HARPST ST
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-8222
Practice Address - Country:US
Practice Address - Phone:707-826-3146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN291407390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104991744OtherHUMBOLDT STATE UNIVERSITY STUDENT HEALTH CENTER