Healthcare Provider Details

I. General information

NPI: 1134578537
Provider Name (Legal Business Name): NICOLE SAMSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 7TH STREET NE - ALTRU CLINIC/DEVILS LAKE
DEVILS LAKE ND
58301-2719
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-2157
  • Fax: 701-780-4391
Mailing address:
  • Phone: 701-780-1891
  • Fax: 701-780-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRL14150
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15356
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: