Provider Demographics
NPI:1568404002
Name:HUDSON, GRACIA TOLENTINO (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACIA
Middle Name:TOLENTINO
Last Name:HUDSON
Suffix:
Gender:F
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 1:3616 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-4117
Mailing Address - Country:US
Mailing Address - Phone:228-872-7684
Mailing Address - Fax:228-762-7109
Practice Address - Street 1:3890 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5803
Practice Address - Country:US
Practice Address - Phone:228-872-6291
Practice Address - Fax:228-875-3385
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS970000006Medicare ID - Type Unspecified