Healthcare Provider Details

I. General information

NPI: 1023067915
Provider Name (Legal Business Name): WAYNE HUDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 N 4TH ST
DOUGLAS WY
82633-2402
US

IV. Provider business mailing address

124 N 4TH ST
DOUGLAS WY
82633-2402
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-9008
  • Fax: 307-358-5183
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number128T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: