Basic Information
| Provider Information | |||||||||
| NPI: | 1518908524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2360 MULLAN RD | ||||||||
| Address2: | STE C | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067214436 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Practice Location | |||||||||
| Address1: | 2360 MULLAN RD | ||||||||
| Address2: | STE C | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067214436 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 273 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 273 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 043788 | 05 | MT | MEDICAID |