Healthcare Provider Details

I. General information

NPI: 1740848878
Provider Name (Legal Business Name): JACI RANEA HODGES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MAIN ST
WOODWARD OK
73801-3043
US

IV. Provider business mailing address

1501 MAIN ST
WOODWARD OK
73801-3043
US

V. Phone/Fax

Practice location:
  • Phone: 580-254-5316
  • Fax: 580-256-6508
Mailing address:
  • Phone: 580-254-5316
  • Fax: 580-256-6508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3097
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: