Provider Demographics
NPI:1033739925
Name:SHUCK, JEREMIAH RYAN
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:RYAN
Last Name:SHUCK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-418-8000
Mailing Address - Fax:
Practice Address - Street 1:2305 37TH AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7669
Practice Address - Country:US
Practice Address - Phone:701-857-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0871363A00000X, 363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program