Provider Demographics
NPI:1841707742
Name:RUTLEDGE, TASHA RENEE (CPNP-PO)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:RENEE
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:CPNP-PO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501
Mailing Address - Country:US
Mailing Address - Phone:541-734-5437
Mailing Address - Fax:541-618-1094
Practice Address - Street 1:816 W 10TH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-734-5437
Practice Address - Fax:541-618-1094
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201710258NP-PP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201710258NP-PPMedicaid