Provider Demographics
NPI:1629219282
Name:FUKUNAGA, DUDLEY
Entity Type:Individual
Prefix:
First Name:DUDLEY
Middle Name:
Last Name:FUKUNAGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-3456
Mailing Address - Country:US
Mailing Address - Phone:562-401-7448
Mailing Address - Fax:
Practice Address - Street 1:7601 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3456
Practice Address - Country:US
Practice Address - Phone:562-401-7448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant