Provider Demographics
NPI:1417605320
Name:RUDD, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:RUDD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3561 LYNNFIELD RD APT 2
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5163
Mailing Address - Country:US
Mailing Address - Phone:614-323-4589
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:614-323-4589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered