Provider Demographics
NPI:1629072475
Name:ZIESKE, RICHARD E (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:ZIESKE
Suffix:
Gender:M
Credentials:PA
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 5126
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5126
Mailing Address - Country:US
Mailing Address - Phone:605-335-1952
Mailing Address - Fax:605-373-9971
Practice Address - Street 1:1727 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-3245
Practice Address - Country:US
Practice Address - Phone:605-275-5560
Practice Address - Fax:605-275-5562
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6823990Medicaid
SD970030684Medicare PIN
SD970023074Medicare PIN
SDS40988Medicare PIN
SDS42259Medicare PIN
SDP55711Medicare UPIN
SDS40994Medicare PIN