Provider Demographics
NPI:1942218102
Name:TRENTADUE, EMILY JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JEAN
Last Name:TRENTADUE
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 1:2885 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4404
Mailing Address - Country:US
Mailing Address - Phone:414-771-6780
Mailing Address - Fax:414-238-2424
Practice Address - Street 1:500 W DREXEL AVE STE 300
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-2060
Practice Address - Country:US
Practice Address - Phone:414-771-6780
Practice Address - Fax:414-238-2424
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2037-23363A00000X
WI2037-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42888500Medicaid
Q71761Medicare UPIN
WI001504130Medicare PIN