Healthcare Provider Details

I. General information

NPI: 1932642790
Provider Name (Legal Business Name): HETLAND EAR NOSE THROAT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 TYLER PKWY STE 6
BISMARCK ND
58503-0871
US

IV. Provider business mailing address

2331 TYLER PKWY STE 6
BISMARCK ND
58503-0871
US

V. Phone/Fax

Practice location:
  • Phone: 701-258-6851
  • Fax: 701-258-6852
Mailing address:
  • Phone: 701-258-6851
  • Fax: 701-258-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number11581
License Number StateND

VIII. Authorized Official

Name: ANDREW RYAN HETLAND
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-934-1393