Provider Demographics
NPI:1285643213
Name:HUDOCK, MARCUS W (PA-C)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:W
Last Name:HUDOCK
Suffix:
Gender:M
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 1:1001 GALAXY WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5725
Mailing Address - Country:US
Mailing Address - Phone:925-225-5837
Mailing Address - Fax:925-225-5838
Practice Address - Street 1:1001 GALAXY WAY STE 400
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5725
Practice Address - Country:US
Practice Address - Phone:925-225-5837
Practice Address - Fax:925-225-5838
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15978146D00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15978Medicaid
CAAN844WMedicare PIN
CA0PA159780Medicare PIN
CAP36436Medicare UPIN
CA0PA159785Medicare PIN
CAPA15978Medicaid
CACP546ZMedicare PIN
CA0PA159782Medicare PIN