MEDICARE: MR. DWAYNE HUDSON

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	376K00000X	Nurse's Aide	49-01-98-9879	IN

General Provider Information

NPI Number	:	1871719328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DWAYNE HUDSON

Provider Business Mailing Address
First Line	:	3900 N SHADELAND AVE
Second Line	:	APT241
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-5169
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 N SHADELAND AVE
Second Line	:	APT241
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-5169
Country	:	US
Telephone Number	:	317-945-9329
Fax Number	:

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

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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Directions to “ MR. DWAYNE HUDSON ” Practice Location

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