Healthcare Provider Details

I. General information

NPI: 1194564591
Provider Name (Legal Business Name): JACOB NICHOLAS BUDKE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 SABATTUS ST
LEWISTON ME
04240-5553
US

IV. Provider business mailing address

3576 COMMONWEALTH RD
WOODBURY MN
55125-4379
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8810
  • Fax:
Mailing address:
  • Phone: 651-276-9169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: