Provider Demographics
NPI:1750908455
Name:WIEDMANN, JORDAN ANN (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ANN
Last Name:WIEDMANN
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 1:2822 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1606
Mailing Address - Country:US
Mailing Address - Phone:701-543-5533
Mailing Address - Fax:
Practice Address - Street 1:4040 42ND ST S STE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4352
Practice Address - Country:US
Practice Address - Phone:701-543-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1174572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant