MEDICARE: EWA ZOFIA DUDA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704228213	MI

General Provider Information

NPI Number	:	1003546250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EWA ZOFIA DUDA

Provider Business Mailing Address
First Line	:	3559 SHADY BEACH BLVD
Second Line	:
City	:	ORCHARD LAKE
State	:	MI
Zip	:	48324-3057
Country	:	US
Telephone Number	:	248-535-2498
Fax Number	:

Provider Business Practice Location Address
First Line	:	3559 SHADY BEACH BLVD
Second Line	:
City	:	ORCHARD LAKE
State	:	MI
Zip	:	48324-3057
Country	:	US
Telephone Number	:	248-535-2498
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2022
Last Update Date	:	06/12/2022

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