Provider Demographics
NPI:1598398018
Name:TRUJILLO, RUBY (PA-C)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:TRUJILLO
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 1:17549 CHERRY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-5138
Mailing Address - Country:US
Mailing Address - Phone:386-559-7878
Mailing Address - Fax:
Practice Address - Street 1:13691 METROPOLIS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4318
Practice Address - Country:US
Practice Address - Phone:239-231-1465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant