Provider Demographics
NPI:1730254996
Name:RUDHOLM, HAYDEE (PA)
Entity type:Individual
Prefix:MRS
First Name:HAYDEE
Middle Name:
Last Name:RUDHOLM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5935 PLAYA VISTA DR APT 102
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2131
Mailing Address - Country:US
Mailing Address - Phone:323-841-0955
Mailing Address - Fax:
Practice Address - Street 1:1701 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1065
Practice Address - Country:US
Practice Address - Phone:323-223-6146
Practice Address - Fax:323-223-6399
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 13119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant