Healthcare Provider Details

I. General information

NPI: 1114740222
Provider Name (Legal Business Name): ANDREW HUNTER HUDSON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SOUTHPARK BLVD STE 100
ST AUGUSTINE FL
32086-4209
US

IV. Provider business mailing address

440 S VILLA SAN MARCO DR UNIT 103
ST AUGUSTINE FL
32086-4153
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-1478
  • Fax: 904-824-8071
Mailing address:
  • Phone: 229-406-2654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT42330
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: