Provider Demographics
NPI:1568402824
Name:DUDLEY, ROBERT A (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8178
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-8178
Mailing Address - Country:US
Mailing Address - Phone:772-201-7510
Mailing Address - Fax:
Practice Address - Street 1:13101 S INDIAN RIVER DR
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-2229
Practice Address - Country:US
Practice Address - Phone:772-229-0059
Practice Address - Fax:772-337-2860
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1447122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034784100Medicaid