Provider Demographics
NPI:1720538630
Name:RUDOLPH, HOLLIE C (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:C
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:200 HYGEIA DR STE 2300
Mailing Address - Street 2:CCHS PHYSICIAN CONTRACTING
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4701 OGLETOWN STANTON ROAD
Practice Address - Street 2:SUITE 2100
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-7000
Practice Address - Country:US
Practice Address - Phone:302-623-4530
Practice Address - Fax:302-623-4578
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEC5-0001093363A00000X
DE363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant