=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104324623
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILLIAN BLAIR TRULSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2018
-----------------------------------------------------
Last Update Date | 11/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20261 E OCOTILLO RD
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-8806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-677-2771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 N GRANITE ST
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85234-4834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-227-6683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 7017
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------