Healthcare Provider Details

I. General information

NPI: 1275794596
Provider Name (Legal Business Name): JEREMY JAMES HOUSER MPAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 11/04/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W GOOD SAMARITAN DR
WARREN MN
56762-1412
US

IV. Provider business mailing address

300 W GOOD SAMARITAN DR
WARREN MN
56762-1412
US

V. Phone/Fax

Practice location:
  • Phone: 218-745-4211
  • Fax: 218-745-3254
Mailing address:
  • Phone: 218-745-4211
  • Fax: 182-745-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: