Healthcare Provider Details

I. General information

NPI: 1962604611
Provider Name (Legal Business Name): JOSE TRUJILLO P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S MACLAY AVE
SAN FERNANDO CA
91340-3603
US

IV. Provider business mailing address

855 N HILL RD
POMONA CA
91768-1641
US

V. Phone/Fax

Practice location:
  • Phone: 818-700-1250
  • Fax: 818-700-1045
Mailing address:
  • Phone: 818-700-1250
  • Fax: 818-700-1045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10997
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: