Provider Demographics
NPI:1336505163
Name:ANDERSON, JILL DUTSON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:DUTSON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6813 PAINTED MORNING AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-3645
Mailing Address - Country:US
Mailing Address - Phone:702-630-8831
Mailing Address - Fax:
Practice Address - Street 1:2050 MARINER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-6656
Practice Address - Country:US
Practice Address - Phone:702-228-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant