Provider Demographics
NPI:1134751902
Name:MUNDAHL, JACIE ANNA (PA-C)
Entity type:Individual
Prefix:
First Name:JACIE
Middle Name:ANNA
Last Name:MUNDAHL
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 1:6008 37TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:RUGBY
Mailing Address - State:ND
Mailing Address - Zip Code:58368-8760
Mailing Address - Country:US
Mailing Address - Phone:701-771-0134
Mailing Address - Fax:
Practice Address - Street 1:8TH AVE C ST E 80
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0001
Practice Address - Country:US
Practice Address - Phone:801-408-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11609094-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant