Provider Demographics
NPI:1295463610
Name:HUDSON, TARYNCE
Entity type:Individual
Prefix:
First Name:TARYNCE
Middle Name:
Last Name:HUDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 N HIGHWAY 79
Mailing Address - Street 2:
Mailing Address - City:SHERRILL
Mailing Address - State:AR
Mailing Address - Zip Code:72152-8824
Mailing Address - Country:US
Mailing Address - Phone:870-592-0049
Mailing Address - Fax:
Practice Address - Street 1:4216 W 28TH ST.
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603
Practice Address - Country:US
Practice Address - Phone:501-653-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12106817432081S0010X, 2083S0010X, 171400000X
AR12106440802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR236Medicaid