Provider Demographics
NPI:1063045789
Name:ROTHERMUND, JODY D (PA-C)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:D
Last Name:ROTHERMUND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:D
Other - Last Name:NOREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1037 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1808
Mailing Address - Country:US
Mailing Address - Phone:701-318-9651
Mailing Address - Fax:
Practice Address - Street 1:415 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1264
Practice Address - Country:US
Practice Address - Phone:218-631-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program