Provider Demographics
NPI:1013362862
Name:TRUJILLO, TYSEN (MD)
Entity Type:Individual
Prefix:
First Name:TYSEN
Middle Name:
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 12TH AVE N STE 205W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7520
Mailing Address - Country:US
Mailing Address - Phone:406-254-0707
Mailing Address - Fax:
Practice Address - Street 1:2900 12TH AVE N STE 205W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7520
Practice Address - Country:US
Practice Address - Phone:406-254-0704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT85265207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1013362862Medicaid