Provider Demographics
NPI:1679398929
Name:MUDGE, JARED (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:MUDGE
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 1:200 S IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7552
Mailing Address - Country:US
Mailing Address - Phone:208-686-5133
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 388
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851-0388
Practice Address - Country:US
Practice Address - Phone:208-686-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5761672363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical