Provider Demographics
NPI:1790066637
Name:RUTHERFORD, DEVON MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DEVON
Middle Name:MARIE
Last Name:RUTHERFORD
Suffix:
Gender:F
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 1:110 HEATH RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9104
Mailing Address - Country:US
Mailing Address - Phone:609-668-5132
Mailing Address - Fax:
Practice Address - Street 1:190 BALDWIN RD
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-2006
Practice Address - Country:US
Practice Address - Phone:609-668-5132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003616363A00000X
MDC0004496363AM0700X
WAPA60863546363AM0700X
NJMP00369700207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ17900666397Other