Provider Demographics
NPI:1285625855
Name:POLYANSKAYA RUPPE, ELENA YURIEVNA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELENA
Middle Name:YURIEVNA
Last Name:POLYANSKAYA RUPPE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 ROCK MERRITT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-7639
Mailing Address - Fax:
Practice Address - Street 1:2817 ROCK MERRITT AVE
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-3411
Practice Address - Country:US
Practice Address - Phone:910-907-7639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ23461Medicare UPIN
NC2760900Medicare ID - Type Unspecified