=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497156640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON THEODORE TRULSON PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2014
-----------------------------------------------------
Last Update Date | 05/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6116 E ARBOR AVE STE 118
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85206-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-648-5444
-----------------------------------------------------
Fax | 602-772-3801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 80217
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85060-0217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-385-2115
-----------------------------------------------------
Fax | 480-418-3323
-----------------------------------------------------
=====================================================
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 | 5799
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 5799
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------