Provider Demographics
NPI:1700864071
Name:TRUJILLO-OLKKONEN, HEATHER A (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:TRUJILLO-OLKKONEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 S ALMA SCHOOL RD STE 354
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3028
Mailing Address - Country:US
Mailing Address - Phone:480-726-2287
Mailing Address - Fax:888-503-3312
Practice Address - Street 1:3130 E BASELINE RD STE 107
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7290
Practice Address - Country:US
Practice Address - Phone:480-345-1980
Practice Address - Fax:480-926-1721
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7057360001332B00000X
AZ7047150001332B00000X
AZ7209350001332B00000X
AZ70349500001332B00000X
AZ7046960001332B00000X
AZ7939960001332B00000X
AZ704516001332B00000X
AZ8220410001332B00000X
AZ7629170001332B00000X
AZ5925363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ974750Medicaid
S83260Medicare UPIN
NM000B7866Medicaid