Provider Demographics
NPI:1174964837
Name:RUIZ, HEDERSON ANIBAL
Entity type:Individual
Prefix:
First Name:HEDERSON
Middle Name:ANIBAL
Last Name:RUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HEDERSON
Other - Middle Name:ANIBAL
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:7003274
Mailing Address - Street 1:12618 109TH CT NE APT H305
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6496
Mailing Address - Country:US
Mailing Address - Phone:206-915-9620
Mailing Address - Fax:
Practice Address - Street 1:12618 109TH CT NE APT H305
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6496
Practice Address - Country:US
Practice Address - Phone:206-915-9620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60325876225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist