Provider Demographics
NPI:1265543151
Name:DETWILER, JOANNE TIKKA (PA-C)
Entity type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:TIKKA
Last Name:DETWILER
Suffix:
Gender:F
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 1:3802 COSPORT CT
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-6936
Mailing Address - Country:US
Mailing Address - Phone:605-791-5385
Mailing Address - Fax:
Practice Address - Street 1:2820 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5462
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:605-721-8439
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD101915Medicare PIN