Provider Demographics
NPI:1518942358
Name:TUDOR, JODY (ARNP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:TUDOR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 CISCO VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-3939
Mailing Address - Country:US
Mailing Address - Phone:850-217-6762
Mailing Address - Fax:
Practice Address - Street 1:2701 S INTERSTATE 35
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7320
Practice Address - Country:US
Practice Address - Phone:512-218-3926
Practice Address - Fax:512-218-0179
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9207392363L00000X
TX639393363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307275400Medicaid
Q32170Medicare UPIN
FL307275400Medicaid