Healthcare Provider Details

I. General information

NPI: 1134697774
Provider Name (Legal Business Name): JESSICA RADERMACHER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 COLFAX AVE SW
WADENA MN
56482-1470
US

IV. Provider business mailing address

421 11TH ST NW
WADENA MN
56482-1044
US

V. Phone/Fax

Practice location:
  • Phone: 320-815-8072
  • Fax:
Mailing address:
  • Phone: 218-631-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12873
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: