=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164809901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MINDA TRUJILLO PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2015
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 FRIST CT
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31909-3578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-288-5046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 LEE ROAD 612
-----------------------------------------------------
City | SMITHS STATION
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36877-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-288-5046
-----------------------------------------------------
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 | 11744
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------