Provider Demographics
NPI:1235207937
Name:TRUDEAU, BRIAN RICHARD (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:RICHARD
Last Name:TRUDEAU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11581 W CREEKRAPIDS DR
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5729
Mailing Address - Country:US
Mailing Address - Phone:208-286-7292
Mailing Address - Fax:
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4882
Practice Address - Country:US
Practice Address - Phone:208-454-9839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1650174Medicare PIN