Provider Demographics
NPI:1053645085
Name:TUDOR, BENJAMIN PATRICK (RPHT, AEMT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:PATRICK
Last Name:TUDOR
Suffix:
Gender:M
Credentials:RPHT, AEMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1309
Mailing Address - Country:US
Mailing Address - Phone:859-533-9481
Mailing Address - Fax:
Practice Address - Street 1:1873 HONEY SPRING PLACE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502
Practice Address - Country:US
Practice Address - Phone:859-533-9481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2011-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00019910PT183700000X
KY2175794276146M00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
No183700000XPharmacy Service ProvidersPharmacy Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other