Provider Demographics
NPI:1063587194
Name:RUDKIN, SHAWN A (DC CCEP)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:A
Last Name:RUDKIN
Suffix:
Gender:M
Credentials:DC CCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660-0154
Mailing Address - Country:US
Mailing Address - Phone:208-722-9999
Mailing Address - Fax:
Practice Address - Street 1:101 E GROVE AVENUE
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:ID
Practice Address - Zip Code:83660-0154
Practice Address - Country:US
Practice Address - Phone:208-722-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA857111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU68984Medicare UPIN
ID1673783Medicare PIN