Healthcare Provider Details

I. General information

NPI: 1508822586
Provider Name (Legal Business Name): JUDE I TARDY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 STATE ST SUITE 330
BANGOR ME
04401-6630
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-8881
  • Fax: 207-973-8880
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA699
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: