Provider Demographics
NPI:1588030613
Name:BAUER, JODY M (PA-C)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:M
Last Name:BAUER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:M
Other - Last Name:KUSMENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4530
Mailing Address - Country:US
Mailing Address - Phone:701-712-4500
Mailing Address - Fax:701-712-4098
Practice Address - Street 1:727 KIRKWOOD MALL
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5753
Practice Address - Country:US
Practice Address - Phone:701-712-4500
Practice Address - Fax:701-712-4011
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1466407Medicaid