Provider Demographics
NPI:1679351217
Name:TUDOR, BAILEY VICTORIA
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:VICTORIA
Last Name:TUDOR
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 1:1440 MOUNT VERNON ST APT 507
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3475
Mailing Address - Country:US
Mailing Address - Phone:508-631-1551
Mailing Address - Fax:
Practice Address - Street 1:1440 MOUNT VERNON ST APT 507
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3475
Practice Address - Country:US
Practice Address - Phone:508-631-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant