Healthcare Provider Details

I. General information

NPI: 1336633296
Provider Name (Legal Business Name): JILL TRUESDALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL CRONK PA-C

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 ALBANY AVE
TORRINGTON WY
82240-1530
US

IV. Provider business mailing address

2000 CAMPBELL DR
TORRINGTON WY
82240-1528
US

V. Phone/Fax

Practice location:
  • Phone: 307-532-2107
  • Fax:
Mailing address:
  • Phone: 307-532-2107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPT765
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0005466
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: