Provider Demographics
NPI:1013064427
Name:DOMINICK, JUDY WU (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:WU
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JUDY
Other - Middle Name:SHAUCHIN
Other - Last Name:WU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2651 REDDING RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-2963
Mailing Address - Country:US
Mailing Address - Phone:404-841-5466
Mailing Address - Fax:
Practice Address - Street 1:2651 REDDING RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-2963
Practice Address - Country:US
Practice Address - Phone:404-841-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02684363A00000X
GA6137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87N556OtherBLUE CROSS
TX970013327OtherRAILROAD MEDICARE
TX970013327OtherRAILROAD MEDICARE
TX87N556OtherBLUE CROSS