Provider Demographics
NPI:1518169903
Name:RODIECK, JEFFERSON LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:LEE
Last Name:RODIECK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1045 CENTRAL PARKWAY NORTH
Mailing Address - Street 2:SUITE #200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-5024
Mailing Address - Country:US
Mailing Address - Phone:210-541-4500
Mailing Address - Fax:210-541-4508
Practice Address - Street 1:408 NAVARRO ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2502
Practice Address - Country:US
Practice Address - Phone:210-272-1741
Practice Address - Fax:210-272-1747
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB135689Medicare PIN