Healthcare Provider Details

I. General information

NPI: 1821155375
Provider Name (Legal Business Name): JAMIE WITT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9645 GROVE CIR N STE 100
MAPLE GROVE MN
55369-4466
US

IV. Provider business mailing address

4225 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4215
US

V. Phone/Fax

Practice location:
  • Phone: 763-302-4114
  • Fax: 763-302-4081
Mailing address:
  • Phone: 763-588-0661
  • Fax: 763-302-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9955
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: