Healthcare Provider Details

I. General information

NPI: 1831793330
Provider Name (Legal Business Name): IAN UDSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 LOFTIS BLVD STE 100
NEWPORT NEWS VA
23606-2981
US

IV. Provider business mailing address

1031 LOFTIS BLVD STE 100
NEWPORT NEWS VA
23606-2981
US

V. Phone/Fax

Practice location:
  • Phone: 757-736-9860
  • Fax:
Mailing address:
  • Phone: 757-736-9860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007951
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: