Healthcare Provider Details

I. General information

NPI: 1760487672
Provider Name (Legal Business Name): JULIE L. TUDOR P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N EAGLE CREEK DR LCE-1
LEXINGTON KY
40509-1805
US

IV. Provider business mailing address

100 N EAGLE CREEK DR LCE-1
LEXINGTON KY
40509-1805
US

V. Phone/Fax

Practice location:
  • Phone: 859-258-5102
  • Fax: 859-258-5177
Mailing address:
  • Phone: 859-258-5102
  • Fax: 859-258-5177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA661
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA661
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA661
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: