MEDICARE: JEFFERSON LEE RODIECK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1518169903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERSON LEE RODIECK PA-C

Provider Business Mailing Address
First Line	:	1045 CENTRAL PARKWAY NORTH
Second Line	:	SUITE #200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-5024
Country	:	US
Telephone Number	:	210-541-4500
Fax Number	:	210-541-4508

Provider Business Practice Location Address
First Line	:	408 NAVARRO ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78205-2502
Country	:	US
Telephone Number	:	210-272-1741
Fax Number	:	210-272-1747

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	01/22/2014

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