Provider Demographics
NPI:1689611212
Name:JAHRAUS, MARY G (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:JAHRAUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:JAHRAUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-224-7070
Mailing Address - Fax:605-224-2514
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-224-7070
Practice Address - Fax:605-224-2514
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0228363A00000X
SD228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD3820713Medicaid
SD6820710Medicaid
SD2107Medicare ID - Type Unspecified
SD6820710Medicaid