Provider Demographics
NPI:1194753095
Name:REDDICK, TRUDY (PA C)
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:
Last Name:REDDICK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5347 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-9346
Mailing Address - Country:US
Mailing Address - Phone:623-330-3222
Mailing Address - Fax:
Practice Address - Street 1:13075 W MCDOWELL RD
Practice Address - Street 2:STE D106
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-6436
Practice Address - Country:US
Practice Address - Phone:480-776-1588
Practice Address - Fax:623-547-0521
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3221363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ973033Medicaid
AZ973033Medicaid