Provider Demographics
NPI:1477590230
Name:HUDENKO, NANCY JEAN (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JEAN
Last Name:HUDENKO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 N STATE ST
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-1089
Practice Address - Country:US
Practice Address - Phone:616-267-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1256003Medicare PIN