Provider Demographics
NPI:1558323089
Name:RUDE, DANIEL O (PAC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:O
Last Name:RUDE
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 1:11104 187TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-7805
Mailing Address - Country:US
Mailing Address - Phone:612-327-6592
Mailing Address - Fax:
Practice Address - Street 1:800 FREEPORT AVE NW
Practice Address - Street 2:SUITE 100B
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2723
Practice Address - Country:US
Practice Address - Phone:763-257-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS76045Medicare UPIN