Provider Demographics
NPI:1225033681
Name:BIETZ, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:BIETZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:41949 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:TRIPP
Mailing Address - State:SD
Mailing Address - Zip Code:57376-7011
Mailing Address - Country:US
Mailing Address - Phone:605-583-2900
Mailing Address - Fax:
Practice Address - Street 1:708 8TH ST
Practice Address - Street 2:
Practice Address - City:ARMOUR
Practice Address - State:SD
Practice Address - Zip Code:57313-2102
Practice Address - Country:US
Practice Address - Phone:605-724-2151
Practice Address - Fax:605-724-2310
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0489363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6823890Medicaid
SD49997104OtherBLUE CROSS
SD6504OtherAVERA HEALTH PLANS
SD23141OtherSIOUX VALLEY HEALTH PLAN
SD6504OtherAVERA HEALTH PLANS