Basic Information
| Provider Information | |||||||||
| NPI: | 1679199863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSKOVICH | ||||||||
| FirstName: | RORY | ||||||||
| MiddleName: | MACK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 PARADISE RD | ||||||||
| Address2: | |||||||||
| City: | GRANGEVILLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835305321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088192476 | ||||||||
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| Practice Location | |||||||||
| Address1: | 277 OHUA AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968153695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089224787 | ||||||||
| FaxNumber: | 8089224950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2020 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.