Provider Demographics
NPI:1609265065
Name:PAVLESICH, RUDOLPH III (DNP, CRNA, FNP-BC)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:
Last Name:PAVLESICH
Suffix:III
Gender:M
Credentials:DNP, CRNA, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 STEVENS HILL RD
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03290-4802
Mailing Address - Country:US
Mailing Address - Phone:904-535-1875
Mailing Address - Fax:
Practice Address - Street 1:16 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1126
Practice Address - Country:US
Practice Address - Phone:603-536-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA281215367500000X
FLARNP9178468367500000X
NH074985-23367500000X
FL2017019797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily