Provider Demographics
NPI:1285884817
Name:TUDOR, ROBIN RENAE (MMS, PA-C)
Entity type:Individual
Prefix:MS
First Name:ROBIN
Middle Name:RENAE
Last Name:TUDOR
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:RENAE
Other - Last Name:SMOLAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS, PA-C
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:85 E US HIGHWAY 6 STE 310
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-983-6380
Practice Address - Fax:219-983-6080
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001201A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1084333OtherNCCPA