Provider Demographics
NPI:1235182254
Name:WUEBBEN, MARY JANE (PAC)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:WUEBBEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6709 S MINNESOTA AVENUE
Mailing Address - Street 2:STE 205
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-0434
Mailing Address - Country:US
Mailing Address - Phone:605-271-1020
Mailing Address - Fax:605-271-2277
Practice Address - Street 1:6709 S MINNESOTA AVE STE 205
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2593
Practice Address - Country:US
Practice Address - Phone:605-271-1020
Practice Address - Fax:605-271-2277
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000871363A00000X
SD0468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS40874Medicare PIN
SD970030008Medicare PIN
SD970030025Medicare PIN
S55309Medicare UPIN