Provider Demographics
NPI:1053990762
Name:RUDER, SHARON LYNN
Entity type:Individual
Prefix:MISS
First Name:SHARON
Middle Name:LYNN
Last Name:RUDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 PAGE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1078
Mailing Address - Country:US
Mailing Address - Phone:517-205-7586
Mailing Address - Fax:517-205-0110
Practice Address - Street 1:4304 PAGE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1078
Practice Address - Country:US
Practice Address - Phone:517-205-7586
Practice Address - Fax:517-205-0110
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000373225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant