Healthcare Provider Details

I. General information

NPI: 1265660740
Provider Name (Legal Business Name): MARK E KOIVULA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 MAIN ST
BOTTINEAU ND
58318-1203
US

IV. Provider business mailing address

PO BOX 419
BOTTINEAU ND
58318-0401
US

V. Phone/Fax

Practice location:
  • Phone: 701-534-0109
  • Fax: 866-640-0723
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR26131
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: