Provider Demographics
NPI:1912122276
Name:RUDDER, WINSTON EARL (PAC)
Entity Type:Individual
Prefix:
First Name:WINSTON
Middle Name:EARL
Last Name:RUDDER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58471 29 PALMS HWY STE 303
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-5818
Mailing Address - Country:US
Mailing Address - Phone:760-365-0851
Mailing Address - Fax:210-582-6601
Practice Address - Street 1:58471 29 PALMS HWY STE 303
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-5818
Practice Address - Country:US
Practice Address - Phone:760-365-0851
Practice Address - Fax:760-365-6848
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15830363A00000X
TXPA09612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15830OtherLICENSE #
TXPA0962OtherMEDICAL LICENSE