Provider Demographics
NPI:1740833565
Name:RUPPERT, JILLIANNE RUSSI (PA)
Entity type:Individual
Prefix:
First Name:JILLIANNE
Middle Name:RUSSI
Last Name:RUPPERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JILLIANNE
Other - Middle Name:MARIE
Other - Last Name:QUINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8030
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:150 TEJAS PL
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9123
Practice Address - Country:US
Practice Address - Phone:805-929-3211
Practice Address - Fax:805-929-6359
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant