Provider Demographics
NPI:1407817794
Name:VULK, JODY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:MARIE
Last Name:VULK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JODY
Other - Middle Name:MARIE
Other - Last Name:SURBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 1ST AVE E
Mailing Address - Street 2:STE C
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4342
Mailing Address - Country:US
Mailing Address - Phone:712-262-7511
Mailing Address - Fax:712-262-3658
Practice Address - Street 1:1200 1ST AVE E
Practice Address - Street 2:STE C
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4342
Practice Address - Country:US
Practice Address - Phone:712-262-7511
Practice Address - Fax:712-262-3658
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001529363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI10874Medicare ID - Type Unspecified
Q03622Medicare UPIN