Provider Demographics
NPI:1477013159
Name:JUDD, KATHLEEN GARDNER
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GARDNER
Last Name:JUDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22415 NORTON CT
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-5441
Mailing Address - Country:US
Mailing Address - Phone:907-764-2322
Mailing Address - Fax:
Practice Address - Street 1:4300 B ST STE 200
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-5933
Practice Address - Country:US
Practice Address - Phone:907-375-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK207301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine