Provider Demographics
NPI:1336633296
Name:TRUESDALE, JILL (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:TRUESDALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:CRONK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2000 CAMPBELL DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1528
Mailing Address - Country:US
Mailing Address - Phone:307-532-2107
Mailing Address - Fax:
Practice Address - Street 1:625 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1530
Practice Address - Country:US
Practice Address - Phone:307-532-2107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT765363A00000X
COPA.0005466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant