Provider Demographics
NPI:1730569153
Name:RUCKDESCHEL, SHARON
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:RUCKDESCHEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 LA SALLE PL
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1859
Mailing Address - Country:US
Mailing Address - Phone:631-563-8559
Mailing Address - Fax:
Practice Address - Street 1:32 LA SALLE PLACE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769
Practice Address - Country:US
Practice Address - Phone:631-563-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY718485257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist