Healthcare Provider Details

I. General information

NPI: 1790753267
Provider Name (Legal Business Name): JILL DIANE BULL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BROADWAY ST CVS/MINUTE CLINIC
PEARLAND TX
77581-4507
US

IV. Provider business mailing address

6060 FAIRMONT PKWY APT. 10307
PASADENA TX
77505-4049
US

V. Phone/Fax

Practice location:
  • Phone: 281-997-4400
  • Fax: 281-997-4400
Mailing address:
  • Phone: 832-236-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04722
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: