Provider Demographics
NPI:1467426387
Name:MEDECK, JONATHAN DEAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DEAN
Last Name:MEDECK
Suffix:
Gender:M
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 3468
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-3468
Mailing Address - Country:US
Mailing Address - Phone:605-343-8000
Mailing Address - Fax:605-343-8262
Practice Address - Street 1:710 SAINT ANNE STREET
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4670
Practice Address - Country:US
Practice Address - Phone:605-343-8000
Practice Address - Fax:605-343-8262
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0361207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD070013292OtherRAILROAD MEDICARE
SD6826630Medicaid
SD6247Medicare ID - Type Unspecified