Healthcare Provider Details

I. General information

NPI: 1356798235
Provider Name (Legal Business Name): JUSTIN DAVID DUDLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO # 116025
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5062
  • Fax:
Mailing address:
  • Phone: 505-272-5560
  • Fax: 505-272-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0003
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: