| Provider / Organization | NPI | Date Certified |
|---|---|---|
| JACK WOODWORTH SAMPLE | 1093393944 | 2021-04-03 |
Jack Woodworth Sample is registered with the National Plan and Provider Enumeration System and has been issued an National Provider Identifier (NPI) of 1093393944. Registration indicates Jack Woodworth Sample is a provider of services with a specialization in Student, Health Care, Student in an Organized Health Care Education/Training Program (Student in an Organized Health Care Education/Training Program, ) (All Other Specialties & Provider Types, ) (Student in an Organized Health Care Education/Training Program, Student, Health Care)
| Entity Type | Individual |
| Provider Name | Jack Woodworth Sample Ii MD |
| Practice Office Address | 200 1ST ST SW ROCHESTER, MN US |
| Practice Office Telephone | 5072842511 |
| Mailing Address | 200 1ST ST SW ROCHESTER, MN 559050001 US |
| Business Telephone | 5072842511 |
| Code | Practice | License No State |
|---|---|---|
| 390200000X PRIMARY | Student, Health Care Student in an Organized Health Care Education/Training Program Student in an Organized Health Care Education/Training Program All Other Specialties & Provider Types Student in an Organized Health Care Education/Training Program Student, Health Care |