Provider Demographics
NPI:1982918074
Name:DUDAS, JESSE SEVERINO
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:SEVERINO
Last Name:DUDAS
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 1:2701 KINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2923
Mailing Address - Country:US
Mailing Address - Phone:919-602-7953
Mailing Address - Fax:
Practice Address - Street 1:3400 WAKE FOREST RD
Practice Address - Street 2:DUKE RALEIGH HOSPITAL
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7317
Practice Address - Country:US
Practice Address - Phone:919-954-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC206465163W00000X
NC085560367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2618471Medicare Oscar/Certification