Basic Information
| Provider Information | |||||||||
| NPI: | 1700864071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRUJILLO-OLKKONEN | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 271429 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841271429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027723800 | ||||||||
| FaxNumber: | 6027723801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 E BANNER GATEWAY DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809642908 | ||||||||
| FaxNumber: | 4808332136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5925 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 974750 | 05 | AZ | MEDICAID |