Provider Demographics
NPI:1073600508
Name:HUDSON, BRYAN K (PA-C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:K
Last Name:HUDSON
Suffix:
Gender:M
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 1:920 N SHADELAND AVE
Mailing Address - Street 2:SUITE G1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4817
Mailing Address - Country:US
Mailing Address - Phone:317-355-9783
Mailing Address - Fax:317-355-9760
Practice Address - Street 1:1700 W STOUT ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-5000
Practice Address - Country:US
Practice Address - Phone:715-236-8104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1632363A00000X
OH50.005985RX363A00000X
IN10000874A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0360999Medicaid
IN251320FFFMedicare PIN