Provider Demographics
NPI:1700205432
Name:RUTLEDGE, RUSSELL RAY III
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:RAY
Last Name:RUTLEDGE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 HIGHWAY 528 NW STE 106
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-8919
Mailing Address - Country:US
Mailing Address - Phone:505-899-4334
Mailing Address - Fax:505-792-4236
Practice Address - Street 1:3615 HIGHWAY 528 NW STE 106
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-8919
Practice Address - Country:US
Practice Address - Phone:505-899-4334
Practice Address - Fax:505-792-4236
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0959225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA-0959OtherNEW MEXICO PHYSICAL THERAPY BOARD