Healthcare Provider Details

I. General information

NPI: 1982918074
Provider Name (Legal Business Name): JESSE SEVERINO DUDAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WAKE FOREST RD DUKE RALEIGH HOSPITAL
RALEIGH NC
27609-7317
US

IV. Provider business mailing address

2701 KINGSLEY RD
RALEIGH NC
27612-2923
US

V. Phone/Fax

Practice location:
  • Phone: 919-954-3939
  • Fax:
Mailing address:
  • Phone: 919-602-7953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number206465
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number085560
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: