Provider Demographics
NPI:1083123277
Name:JUDY-FUDGE, ELIZABETH B (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:B
Last Name:JUDY-FUDGE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8708
Practice Address - Country:US
Practice Address - Phone:208-302-1200
Practice Address - Fax:208-302-1255
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1680363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical