Provider Demographics
NPI:1356099691
Name:RUDER, SAMANTHA A (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:A
Last Name:RUDER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N PACIFIC COAST HWY STE 2175
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5639
Mailing Address - Country:US
Mailing Address - Phone:877-878-3289
Mailing Address - Fax:
Practice Address - Street 1:222 N PACIFIC COAST HWY STE 2175
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5639
Practice Address - Country:US
Practice Address - Phone:877-878-3289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP00065363L00000X
TX1161910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner