Provider Demographics
NPI:1932391083
Name:JORGENSEN, WAYNE ALEXANDER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:ALEXANDER
Last Name:JORGENSEN
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 1:1305 15TH ST NE APT 314
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:243 WINKLER TRL
Practice Address - Street 2:
Practice Address - City:COLOGNE
Practice Address - State:MN
Practice Address - Zip Code:55322-8013
Practice Address - Country:US
Practice Address - Phone:612-720-3985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1044363A00000X
MN10335363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN812998000Medicaid