Provider Demographics
NPI:1811620420
Name:RUDD, JUSTIN D (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:RUDD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8188 US HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-1750
Mailing Address - Country:US
Mailing Address - Phone:901-614-4455
Mailing Address - Fax:901-614-4526
Practice Address - Street 1:8188 US HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-1750
Practice Address - Country:US
Practice Address - Phone:901-614-4455
Practice Address - Fax:901-614-4526
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN5315363A00000X
TN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant