Provider Demographics
NPI:1205126190
Name:HUDSON, MEGAN MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:MARIE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:863-630-6528
Practice Address - Street 1:4700 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-8531
Practice Address - Country:US
Practice Address - Phone:863-603-6504
Practice Address - Fax:863-284-6824
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105941363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEV537ZMedicare UPIN