Provider Demographics
NPI:1649358615
Name:RUDY, TODD A (PA-C)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:RUDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 W WELLSBORO ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-1411
Mailing Address - Country:US
Mailing Address - Phone:570-662-1945
Mailing Address - Fax:570-662-2390
Practice Address - Street 1:103 FORESTVIEW AVE
Practice Address - Street 2:
Practice Address - City:ELKLAND
Practice Address - State:PA
Practice Address - Zip Code:16920-1403
Practice Address - Country:US
Practice Address - Phone:814-258-5117
Practice Address - Fax:814-258-5510
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002854L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S85599Medicare UPIN
PA029144JT3Medicare PIN
PA066294Medicare ID - Type Unspecified