Provider Demographics
NPI:1982103396
Name:CAUDILL, DUSTIN (PA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:CAUDILL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 CYPRESS CROSSING TRL
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6808
Mailing Address - Country:US
Mailing Address - Phone:574-551-5160
Mailing Address - Fax:
Practice Address - Street 1:1708 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3836
Practice Address - Country:US
Practice Address - Phone:574-551-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55108363A00000X
FLPA9113302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant