Provider Demographics
NPI:1811176308
Name:UDAN, JENNIFER LYNN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:UDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:8830 BELAIR RD
Practice Address - Street 2:SURGICAL PA'S
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-2401
Practice Address - Country:US
Practice Address - Phone:410-529-9200
Practice Address - Fax:410-529-9203
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003596363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD352437ZDDBMedicare PIN
MD568426YWV2Medicare PIN
MD352437YVZMedicare PIN