Healthcare Provider Details

I. General information

NPI: 1679398929
Provider Name (Legal Business Name): JARED MUDGE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 388
PLUMMER ID
83851-0388
US

IV. Provider business mailing address

200 S IDAHO ST
POST FALLS ID
83854-7552
US

V. Phone/Fax

Practice location:
  • Phone: 208-686-5133
  • Fax:
Mailing address:
  • Phone: 208-686-5133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5761672
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: