Provider Demographics
NPI:1790753267
Name:BULL, JILL DIANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:DIANE
Last Name:BULL
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 1:6060 FAIRMONT PKWY
Mailing Address - Street 2:APT. 10307
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-4049
Mailing Address - Country:US
Mailing Address - Phone:832-236-2142
Mailing Address - Fax:
Practice Address - Street 1:2900 BROADWAY ST
Practice Address - Street 2:CVS/MINUTE CLINIC
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-4507
Practice Address - Country:US
Practice Address - Phone:281-997-4400
Practice Address - Fax:281-997-4400
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L2607Medicare PIN