Provider Demographics
NPI:1568404002
Name:HUDSON, GRACIA TOLENTINO (PA-C)
Entity type:Individual
Prefix:
First Name:GRACIA
Middle Name:TOLENTINO
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 1:903 W MARTIN ST # MS 49-2
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-0903
Mailing Address - Country:US
Mailing Address - Phone:210-358-0572
Mailing Address - Fax:210-358-5940
Practice Address - Street 1:903 W MARTIN ST # MS 49-2
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-0903
Practice Address - Country:US
Practice Address - Phone:210-743-4324
Practice Address - Fax:210-702-4136
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00029363A00000X
TXPA18149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS970000006Medicare ID - Type Unspecified