Provider Demographics
NPI:1518908524
Name:HUDSON, WADE L (PA C)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:L
Last Name:HUDSON
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 1:2360 MULLAN RD
Mailing Address - Street 2:STE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1811
Mailing Address - Country:US
Mailing Address - Phone:406-721-4436
Mailing Address - Fax:406-721-3907
Practice Address - Street 1:2360 MULLAN RD
Practice Address - Street 2:STE C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-721-4436
Practice Address - Fax:406-721-3907
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT273363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT043788Medicaid
MT000082185Medicare ID - Type Unspecified
MT043788Medicaid