Provider Demographics
NPI:1447285036
Name:HUDSON, CONNIE K (PA)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:K
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1173
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6414 FANNIN ST STE G150
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1514
Practice Address - Country:US
Practice Address - Phone:832-325-7125
Practice Address - Fax:713-512-2200
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00202363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89BN454OtherBCBS
TX184605701Medicaid
TX87N401Medicare PIN
TX970025362Medicare PIN
TX184605701Medicaid