Healthcare Provider Details

I. General information

NPI: 1467426387
Provider Name (Legal Business Name): JONATHAN DEAN MEDECK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 09/28/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANFORD HEALTH TOWER ROAD CLINIC 3024 TOWER ROAD
RAPID CITY SD
57701
US

IV. Provider business mailing address

3024 TOWER ROAD
RAPID CITY SD
57701
US

V. Phone/Fax

Practice location:
  • Phone: 605-508-3000
  • Fax: 605-401-6715
Mailing address:
  • Phone: 605-508-3000
  • Fax: 605-401-6715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0361
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0361
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: