Provider Demographics
NPI:1871643304
Name:RUTAN, THOMAS C (RN, APN, C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:RUTAN
Suffix:
Gender:M
Credentials:RN, APN, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MIDSUMMER DR
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2712
Mailing Address - Country:US
Mailing Address - Phone:732-607-0223
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN ST
Practice Address - Street 2:SUITE 7100
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC08521200364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8382905Medicaid
NJP20624Medicare UPIN
NJ044124Medicare ID - Type UnspecifiedMEDICARE ID