Provider Demographics
NPI:1063407013
Name:RUFFALO, THOMAS (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:RUFFALO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 S SAWYER RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9243
Mailing Address - Country:US
Mailing Address - Phone:262-244-7693
Mailing Address - Fax:
Practice Address - Street 1:791 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3844
Practice Address - Country:US
Practice Address - Phone:262-569-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI657-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42936300Medicaid
WI42936300Medicaid
WIS18227Medicare UPIN