Provider Demographics
NPI:1679098818
Name:DUTRA, JILL O (PA-C)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:O
Last Name:DUTRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:617-726-3884
Mailing Address - Fax:
Practice Address - Street 1:770 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-3437
Practice Address - Country:US
Practice Address - Phone:603-742-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1291363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3110787Medicaid