MEDICARE: JACI RANEA HODGES 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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	3097	OK

General Provider Information

NPI Number	:	1740848878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACI RANEA HODGES PA-C

Provider Business Mailing Address
First Line	:	1501 MAIN ST
Second Line	:
City	:	WOODWARD
State	:	OK
Zip	:	73801-3043
Country	:	US
Telephone Number	:	580-254-5316
Fax Number	:	580-256-6508

Provider Business Practice Location Address
First Line	:	1501 MAIN ST
Second Line	:
City	:	WOODWARD
State	:	OK
Zip	:	73801-3043
Country	:	US
Telephone Number	:	580-254-5316
Fax Number	:	580-256-6508

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

Provider Enumeration Date	:	06/04/2019
Last Update Date	:	02/10/2021

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