Provider Demographics
NPI:1831993799
Name:JANKE, MARY L (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:JANKE
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 1:48859 428TH ST
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-8821
Mailing Address - Country:US
Mailing Address - Phone:701-219-3262
Mailing Address - Fax:
Practice Address - Street 1:48859 428TH ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-8821
Practice Address - Country:US
Practice Address - Phone:701-219-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN15417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program