Provider Demographics
NPI:1871579466
Name:TONELLO, HEATHER R (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:R
Last Name:TONELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:R
Other - Last Name:PRZYBYLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9249 W LAKE CITY RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9602
Mailing Address - Country:US
Mailing Address - Phone:989-422-5122
Mailing Address - Fax:989-422-4378
Practice Address - Street 1:9249 W LAKE CITY RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9602
Practice Address - Country:US
Practice Address - Phone:989-422-5122
Practice Address - Fax:989-422-4378
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004123363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN91010001Medicare ID - Type Unspecified
MIQ15809Medicare UPIN