Provider Demographics
NPI:1114975661
Name:JUDD, MARY ELAINE (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELAINE
Last Name:JUDD
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 1:173 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NH
Mailing Address - Zip Code:03584-3508
Mailing Address - Country:US
Mailing Address - Phone:603-788-5029
Mailing Address - Fax:603-788-5059
Practice Address - Street 1:43 MAIN ST
Practice Address - Street 2:
Practice Address - City:N STRATFORD
Practice Address - State:NH
Practice Address - Zip Code:03590-4005
Practice Address - Country:US
Practice Address - Phone:603-922-5039
Practice Address - Fax:603-922-5502
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0192 P363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOAP1435Medicaid
NH30005368Medicaid
394376OtherMVP HEALTHPLANS
VT00029222OtherBCBS OF VT
7626041OtherAETNA
VTOAP1435Medicaid
394376OtherMVP HEALTHPLANS