Provider Demographics
NPI:1104324623
Name:TRULSON, JILLIAN BLAIR
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:BLAIR
Last Name:TRULSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4834
Mailing Address - Country:US
Mailing Address - Phone:480-227-6683
Mailing Address - Fax:
Practice Address - Street 1:20261 E OCOTILLO RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-8806
Practice Address - Country:US
Practice Address - Phone:480-677-2771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
14949926OtherCAQH