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
State | License ID | Taxonomies |
---|---|---|
TX | PA02684 | 363A00000X |
GA | 6137 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 87N556 | Other | BLUE CROSS |
TX | 970013327 | Other | RAILROAD MEDICARE |
TX | 970013327 | Other | RAILROAD MEDICARE |
TX | 87N556 | Other | BLUE CROSS |