Provider Demographics
NPI:1154713188
Name:RUDY, STACY MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:RUDY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1902
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:
Practice Address - Street 1:6640 SW REDWOOD LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-7187
Practice Address - Country:US
Practice Address - Phone:503-620-7358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA179627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant