Provider Demographics
NPI:1912558107
Name:RUDD, MICHAEL SCOTT (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:RUDD
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 NILES CORTLAND RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1055
Mailing Address - Country:US
Mailing Address - Phone:330-856-2520
Mailing Address - Fax:330-856-2530
Practice Address - Street 1:1932 NILES CORTLAND RD NE STE B
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1055
Practice Address - Country:US
Practice Address - Phone:330-856-2520
Practice Address - Fax:330-856-2530
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025735363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0384154Medicaid