Provider Demographics
NPI:1538480660
Name:RUCKMAN, LISA NOELLE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NOELLE
Last Name:RUCKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 C AVE E
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-4246
Mailing Address - Country:US
Mailing Address - Phone:641-672-3360
Mailing Address - Fax:641-672-3466
Practice Address - Street 1:1229 C AVE E
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-4246
Practice Address - Country:US
Practice Address - Phone:641-672-3360
Practice Address - Fax:641-672-3466
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA41495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine