Provider Demographics
NPI:1982679650
Name:HEDLUND, JEFFREY SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:HEDLUND
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 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:21 WILEY AVE S
Practice Address - Street 2:
Practice Address - City:LIDGERWOOD
Practice Address - State:ND
Practice Address - Zip Code:58053-4001
Practice Address - Country:US
Practice Address - Phone:701-538-4189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0453363A00000X
MN11947363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN722338Medicare PIN
MNH400265189Medicare PIN
Q52533Medicare UPIN