Basic Information
| Provider Information | |||||||||
| NPI: | 1083918460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YUDIS | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 S. GULPH RD | ||||||||
| Address2: | ATT: IPM CREDENTIALING | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753569393 | ||||||||
| FaxNumber: | 7753565590 | ||||||||
| Practice Location | |||||||||
| Address1: | 13421 S SHORE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334147210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614401616 | ||||||||
| FaxNumber: | 5614402030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP3413032 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | ARNP3413032 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 005543800 | 05 | FL | MEDICAID |