Provider Demographics
NPI:1053620344
Name:RUTHERFORD, ALYSSA MAUREEN (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MAUREEN
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:AUBRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5000
Practice Address - Country:US
Practice Address - Phone:734-936-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005725363A00000X
TXPA06912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX830N84OtherBCBS
TX217915201Medicaid
TXTXB115634Medicare PIN