Provider Demographics
NPI:1366738874
Name:RUDDY, PAETRA JANE (MD)
Entity type:Individual
Prefix:DR
First Name:PAETRA
Middle Name:JANE
Last Name:RUDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1793 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2541
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:19917 7TH AVE NE STE 203
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6555
Practice Address - Country:US
Practice Address - Phone:360-824-5474
Practice Address - Fax:360-994-4975
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026116207N00000X
WAMD61231855207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200024055Medicaid