Provider Demographics
NPI:1679199863
Name:RUSKOVICH, RORY MACK (PA-C)
Entity Type:Individual
Prefix:
First Name:RORY
Middle Name:MACK
Last Name:RUSKOVICH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-6390 KAPOLEI PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-6380
Mailing Address - Country:US
Mailing Address - Phone:808-691-8200
Mailing Address - Fax:
Practice Address - Street 1:91-6390 KAPOLEI PKWY STE 200
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-6380
Practice Address - Country:US
Practice Address - Phone:808-691-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-998363A00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered