Provider Demographics
NPI:1144269705
Name:RUDY, DIANNA (PA)
Entity type:Individual
Prefix:MISS
First Name:DIANNA
Middle Name:
Last Name:RUDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 BELVEDERE ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-4001
Mailing Address - Country:US
Mailing Address - Phone:717-243-1653
Mailing Address - Fax:717-243-6708
Practice Address - Street 1:804 BELVEDERE ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-4001
Practice Address - Country:US
Practice Address - Phone:717-243-1653
Practice Address - Fax:717-243-6708
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002847L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50047031OtherCAPITOL BLUE CROSS PROV N