Healthcare Provider Details

I. General information

NPI: 1669447819
Provider Name (Legal Business Name): JILL YVONNE DUDLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GREENLEY RD
SONORA CA
95370-5200
US

IV. Provider business mailing address

23198 HARDSCRABBLE CT
SONORA CA
95370-8535
US

V. Phone/Fax

Practice location:
  • Phone: 209-536-5000
  • Fax: 209-536-3505
Mailing address:
  • Phone: 209-586-9200
  • Fax: 209-586-9300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: