Provider Demographics
NPI:1073505780
Name:GIVANT, JOLENE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:MARIE
Last Name:GIVANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4104
Mailing Address - Country:US
Mailing Address - Phone:515-271-1710
Mailing Address - Fax:515-271-1575
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1710
Practice Address - Fax:515-271-1575
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S80578Medicare UPIN
IAI0114Medicare PIN