Provider Demographics
NPI:1669447819
Name:DUDLEY, JILL YVONNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:YVONNE
Last Name:DUDLEY
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 1:23198 HARDSCRABBLE CT
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8535
Mailing Address - Country:US
Mailing Address - Phone:209-586-9200
Mailing Address - Fax:209-586-9300
Practice Address - Street 1:1000 GREENLEY RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5200
Practice Address - Country:US
Practice Address - Phone:209-536-5000
Practice Address - Fax:209-536-3505
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA126350Medicaid
CAZZZ22859ZMedicare ID - Type Unspecified
CAP88885Medicare UPIN