Provider Demographics
NPI:1326373317
Name:WICHMANN, JESSICA RAYE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAYE
Last Name:WICHMANN
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:PO BOX 5210
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5210
Mailing Address - Country:US
Mailing Address - Phone:218-310-2733
Mailing Address - Fax:
Practice Address - Street 1:2650 32ND AVE S STE D
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6541
Practice Address - Country:US
Practice Address - Phone:701-732-2700
Practice Address - Fax:701-732-2701
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0628363A00000X
MN10660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1467147Medicaid
MN970004432Medicaid