Healthcare Provider Details

I. General information

NPI: 1497982169
Provider Name (Legal Business Name): JENNIFER LEA HODNY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER CILZ

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 S WASHINGTON ST - ALTRU PROFESSIONAL CENTER
GRAND FORKS ND
58201
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-732-7700
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12448
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0688
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: