Basic Information
| Provider Information | |||||||||
| NPI: | 1114975661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUDD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 173 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035843508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037885029 | ||||||||
| FaxNumber: | 6037885059 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | N STRATFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035904005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039225039 | ||||||||
| FaxNumber: | 6039225502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0192 P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | OAP1435 | 05 | VT | MEDICAID | 30005368 | 05 | NH | MEDICAID | 394376 | 01 | MVP HEALTHPLANS | OTHER | 00029222 | 01 | VT | BCBS OF VT | OTHER | 7626041 | 01 | AETNA | OTHER |