Basic Information
Provider Information | |||||||||
NPI: | 1669709499 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUDSON | ||||||||
FirstName: | TIM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 213 S JEFFERSON ST | ||||||||
Address2: | SUITE 625 | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240111700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5402245688 | ||||||||
FaxNumber: | 5402245684 | ||||||||
Practice Location | |||||||||
Address1: | 2900 LAMB CIR | ||||||||
Address2: |   | ||||||||
City: | CHRISTIANSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 240736344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407312800 | ||||||||
FaxNumber: | 5407312874 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2009 | ||||||||
LastUpdateDate: | 03/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0024-168679 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163W00000X | 0001129265 | VA | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.