Basic Information
| Provider Information | |||||||||
| NPI: | 1013422856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUDALA | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 UNIVERSITY DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189401873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157105522 | ||||||||
| FaxNumber: | 2157105181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1203 LANGHORNE NEWTOWN RD STE 226 | ||||||||
| Address2: | |||||||||
| City: | LANGHORNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190471224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157105522 | ||||||||
| FaxNumber: | 2157105181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2017 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA004390 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 25MP00457000 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA059548 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.