Provider Demographics
NPI:1710238126
Name:DUDLEY, JOHN A (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DUDLEY
Suffix:
Gender:M
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 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:1250 FOREST AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1889
Practice Address - Country:US
Practice Address - Phone:207-797-5753
Practice Address - Fax:207-797-9571
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5164390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ749101Medicaid
AZZ91624Medicare PIN