Provider Demographics
NPI:1073829818
Name:MUDGE, DAVID ELLIOTT (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ELLIOTT
Last Name:MUDGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E. DUNLAP
Mailing Address - Street 2:STE 105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020
Mailing Address - Country:US
Mailing Address - Phone:602-944-4626
Mailing Address - Fax:602-944-2805
Practice Address - Street 1:50 E DUNLAP
Practice Address - Street 2:STE 105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020
Practice Address - Country:US
Practice Address - Phone:602-944-4626
Practice Address - Fax:602-944-2805
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical