Provider Demographics
NPI:1982971719
Name:RUDISILL, TARA JO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:JO
Last Name:RUDISILL
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:PO BOX 980631
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0631
Mailing Address - Country:US
Mailing Address - Phone:804-828-9165
Mailing Address - Fax:804-628-0783
Practice Address - Street 1:417 N 11TH ST
Practice Address - Street 2:SIXTH FLOOR
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5002
Practice Address - Country:US
Practice Address - Phone:804-828-9165
Practice Address - Fax:804-628-0783
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2014-02-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10001346A363A00000X
VA0110004072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant