Provider Demographics
NPI:1982866679
Name:RUDEN, NATHAN M (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:M
Last Name:RUDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SE STRATUS AVE
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6255
Mailing Address - Country:US
Mailing Address - Phone:503-435-4514
Mailing Address - Fax:503-472-8691
Practice Address - Street 1:1940 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2317
Practice Address - Country:US
Practice Address - Phone:801-448-2094
Practice Address - Fax:801-657-4662
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD187005207Q00000X
UT73767701205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1982866679Medicaid
UTU000074109Medicare PIN