Provider Demographics
NPI:1467609784
Name:RUCKER, EDLA J (NP)
Entity Type:Individual
Prefix:
First Name:EDLA
Middle Name:J
Last Name:RUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2617
Mailing Address - Country:US
Mailing Address - Phone:575-542-2369
Mailing Address - Fax:575-542-2388
Practice Address - Street 1:530 DE MOSS ST
Practice Address - Street 2:
Practice Address - City:LORDSBURG
Practice Address - State:NM
Practice Address - Zip Code:88045-2617
Practice Address - Country:US
Practice Address - Phone:575-542-8384
Practice Address - Fax:575-542-2388
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10100363LF0000X
NMCNP-03224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810017550Medicaid
OH2943499Medicaid
OHP01046643OtherRAILROAD MEDICARE
WVWV1240AMedicaid
WV3810017550Medicaid
OHH081681Medicare PIN