Healthcare Provider Details

I. General information

NPI: 1750908455
Provider Name (Legal Business Name): JORDAN ANN WIEDMANN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 42ND ST S STE N
FARGO ND
58104-4352
US

IV. Provider business mailing address

2822 2ND ST N
FARGO ND
58102-1606
US

V. Phone/Fax

Practice location:
  • Phone: 701-543-5533
  • Fax:
Mailing address:
  • Phone: 701-543-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1174572
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: