Provider Demographics
NPI:1689389496
Name:HUDAK, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:HUDAK
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 1:1705 LIATRIS LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-6593
Mailing Address - Country:US
Mailing Address - Phone:919-623-9681
Mailing Address - Fax:
Practice Address - Street 1:8311 BANDFORD WAY STE 103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2763
Practice Address - Country:US
Practice Address - Phone:919-845-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC1689389496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program