Provider Demographics
NPI:1386413409
Name:RUDAS-GARCIA, MARCO ANTONIO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:RUDAS-GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARCO
Other - Middle Name:
Other - Last Name:RUDAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1929 W 2295 S
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2600
Mailing Address - Country:US
Mailing Address - Phone:385-416-7071
Mailing Address - Fax:
Practice Address - Street 1:1929 W 2295 S
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84087-2600
Practice Address - Country:US
Practice Address - Phone:385-416-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9819736-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health