Provider Demographics
NPI:1548655921
Name:PETERSEN, TRUDI J (NP)
Entity type:Individual
Prefix:
First Name:TRUDI
Middle Name:J
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRUDI
Other - Middle Name:J
Other - Last Name:MEADOWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 SHATTUCK AVE # 75
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-3402
Mailing Address - Country:US
Mailing Address - Phone:510-435-6185
Mailing Address - Fax:
Practice Address - Street 1:1700 SHATTUCK AVE # 75
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-3402
Practice Address - Country:US
Practice Address - Phone:510-435-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA432166363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology