Provider Demographics
NPI:1972560480
Name:JUDD, ELLEN K (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:K
Last Name:JUDD
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:208-734-3313
Practice Address - Street 1:1308 BENNETT AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2665
Practice Address - Country:US
Practice Address - Phone:208-678-7796
Practice Address - Fax:208-678-7799
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-11-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-98363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS59420Medicare UPIN