Healthcare Provider Details

I. General information

NPI: 1407254303
Provider Name (Legal Business Name): JERRICA TRUJILLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 FOOTHILLS RD
LAS CRUCES NM
88011-3626
US

IV. Provider business mailing address

3530 FOOTHILLS RD
LAS CRUCES NM
88011-3626
US

V. Phone/Fax

Practice location:
  • Phone: 575-535-6054
  • Fax:
Mailing address:
  • Phone: 575-535-6054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2014-0092
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: