Provider Demographics
NPI:1801102074
Name:HUDEK, HEIDI (PA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:HUDEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N BROAD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:267-479-4142
Mailing Address - Fax:
Practice Address - Street 1:1015 CHESTNUT ST STE 512
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4305
Practice Address - Country:US
Practice Address - Phone:267-479-4180
Practice Address - Fax:215-873-0201
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051887363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1039678100001Medicaid