Healthcare Provider Details

I. General information

NPI: 1760154280
Provider Name (Legal Business Name): RYAN ANTON KEFFELER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2021
Last Update Date: 10/03/2021
Certification Date: 10/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 4TH ST S
CARRINGTON ND
58421
US

IV. Provider business mailing address

2349 80TH AVE SE
BUCHANAN ND
58420
US

V. Phone/Fax

Practice location:
  • Phone: 701-652-3141
  • Fax:
Mailing address:
  • Phone: 701-320-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR30675
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: