Provider Demographics
NPI:1093721540
Name:HUDSON, KESHA KATINA (PA-C)
Entity Type:Individual
Prefix:
First Name:KESHA
Middle Name:KATINA
Last Name:HUDSON
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 1:11919 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-2158
Mailing Address - Country:US
Mailing Address - Phone:760-948-1454
Mailing Address - Fax:706-322-8332
Practice Address - Street 1:11919 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-2158
Practice Address - Country:US
Practice Address - Phone:760-948-1454
Practice Address - Fax:706-322-8332
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005383363A00000X
CAPA16506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA16506AMedicare PIN
CAP72258Medicare UPIN