Healthcare Provider Details

I. General information

NPI: 1629541172
Provider Name (Legal Business Name): EVOLVE DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 9TH ST
BISMARCK ND
58501-4530
US

IV. Provider business mailing address

1646 28TH AVE. S. #10
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-712-4899
  • Fax: 701-712-4225
Mailing address:
  • Phone: 701-740-0052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER TINKLER
Title or Position: OWNER
Credential: FNP
Phone: 701-740-0052