Provider Demographics
NPI:1942523600
Name:RUCKMAN, KENDRA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:M
Last Name:RUCKMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:M
Other - Last Name:DEWEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 E NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1950
Practice Address - Country:US
Practice Address - Phone:321-361-5620
Practice Address - Fax:321-434-3511
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005799363A00000X
FLPA9106918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013210300Medicaid
FLY0E5EOtherFLORIDA BLUE (BCBS)
FLGO616YOtherFL MEDICARE
FLP01165565OtherFL RR MEDICARE
FL9284904OtherAETNA