Provider Demographics
NPI:1104312834
Name:RUDOLPH, NICHOLAS LEE
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:LEE
Last Name:RUDOLPH
Suffix:
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 1:320 22ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093-2670
Mailing Address - Country:US
Mailing Address - Phone:507-461-1998
Mailing Address - Fax:
Practice Address - Street 1:501 STATE ST N
Practice Address - Street 2:
Practice Address - City:WASECA
Practice Address - State:MN
Practice Address - Zip Code:56093-2811
Practice Address - Country:US
Practice Address - Phone:507-781-8261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist