Provider Demographics
NPI:1053465765
Name:LUNDEEN, HEIDI (PAC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:LUNDEEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E OLD RANCH RD
Mailing Address - Street 2:
Mailing Address - City:ALLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98524-7711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2520 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4229
Practice Address - Country:US
Practice Address - Phone:360-377-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant