Healthcare Provider Details

I. General information

NPI: 1871579466
Provider Name (Legal Business Name): HEATHER R TONELLO P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER R PRZYBYLO PA-C

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9249 W LAKE CITY RD
HOUGHTON LAKE MI
48629-9602
US

IV. Provider business mailing address

9249 W LAKE CITY RD
HOUGHTON LAKE MI
48629-9602
US

V. Phone/Fax

Practice location:
  • Phone: 989-422-5122
  • Fax: 989-422-4378
Mailing address:
  • Phone: 989-422-5122
  • Fax: 989-422-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601004123
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: