Healthcare Provider Details

I. General information

NPI: 1417403999
Provider Name (Legal Business Name): JORDAN HOFFMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 5TH ST
RAPID CITY SD
57701-6022
US

IV. Provider business mailing address

4150 5TH ST
RAPID CITY SD
57701-6022
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-4300
  • Fax:
Mailing address:
  • Phone: 605-755-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1049
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: