Provider Demographics
NPI:1548415508
Name:FOX, JUDE
Entity Type:Individual
Prefix:
First Name:JUDE
Middle Name:
Last Name:FOX
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 1:16319 THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446
Mailing Address - Country:US
Mailing Address - Phone:707-869-5977
Mailing Address - Fax:707-869-5976
Practice Address - Street 1:16319 THIRD STREET
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446
Practice Address - Country:US
Practice Address - Phone:707-869-5977
Practice Address - Fax:707-869-5976
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19987363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356344758Medicaid
CAZZZ73222ZOtherMEDICARE NHIC
CAZZZ21461ZOtherMEDICARE NHIC
CA237310613OtherBX/BS
CA1598768962Medicaid
CA551803Medicare Oscar/Certification
CA237310613OtherBX/BS