Provider Demographics
NPI:1710234943
Name:RUDISILL, KRISTYN C (PA)
Entity Type:Individual
Prefix:MS
First Name:KRISTYN
Middle Name:C
Last Name:RUDISILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTYN
Other - Middle Name:C
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-4571
Practice Address - Fax:804-828-7710
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003975363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical