Provider Demographics
NPI:1174099733
Name:HUDSON, CRYSTAL NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 CYPRESS GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7559
Mailing Address - Country:US
Mailing Address - Phone:407-203-9485
Mailing Address - Fax:
Practice Address - Street 1:1136 CYPRESS GLEN CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7559
Practice Address - Country:US
Practice Address - Phone:407-203-9485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant