Provider Demographics
NPI:1992263545
Name:RUDGE, ETHAN CHRISTOPHER (RN, BSN, SRNA)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:CHRISTOPHER
Last Name:RUDGE
Suffix:
Gender:M
Credentials:RN, BSN, SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 TURNBUCKLE CT
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8992
Mailing Address - Country:US
Mailing Address - Phone:773-220-4387
Mailing Address - Fax:
Practice Address - Street 1:401 FERNDALE BLVD
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4739
Practice Address - Country:US
Practice Address - Phone:336-882-2567
Practice Address - Fax:336-882-5466
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-03
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC124160367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty