Healthcare Provider Details

I. General information

NPI: 1790859858
Provider Name (Legal Business Name): HEATHER M TRUDEAU PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S HAGADORN RD STE 600
EAST LANSING MI
48823-5383
US

IV. Provider business mailing address

804 SERVICE RD STE A202
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-355-4205
  • Fax: 517-355-4202
Mailing address:
  • Phone: 517-355-4205
  • Fax: 517-355-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004905
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: