Provider Demographics
NPI:1760883623
Name:JUDD, CARRIE MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:MARIE
Last Name:JUDD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:MARIE
Other - Last Name:SPEARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:1824 LATHERS ST
Mailing Address - Street 2:GARDEN CITY
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-3035
Mailing Address - Country:US
Mailing Address - Phone:734-837-4907
Mailing Address - Fax:
Practice Address - Street 1:19933 W 13 MILE RD
Practice Address - Street 2:SOUTHFIELD
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1024
Practice Address - Country:US
Practice Address - Phone:248-203-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant