Provider Demographics
NPI:1760487672
Name:TUDOR, JULIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:TUDOR
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 1:100 N EAGLE CREEK DR
Mailing Address - Street 2:LCE-1
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1805
Mailing Address - Country:US
Mailing Address - Phone:859-258-5102
Mailing Address - Fax:859-258-5177
Practice Address - Street 1:100 N EAGLE CREEK DR
Practice Address - Street 2:LCE-1
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1805
Practice Address - Country:US
Practice Address - Phone:859-258-5102
Practice Address - Fax:859-258-5177
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA661363AS0400X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003299Medicaid
KYP400019608Medicare PIN
KY0169Medicare PIN