Healthcare Provider Details

I. General information

NPI: 1326456963
Provider Name (Legal Business Name): GREAT PLAINS CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 9TH ST W
DICKINSON ND
58601-3950
US

IV. Provider business mailing address

33 9TH ST W
DICKINSON ND
58601-3950
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-6017
  • Fax: 701-483-5018
Mailing address:
  • Phone: 701-483-6017
  • Fax: 701-483-5018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0565
License Number StateND

VIII. Authorized Official

Name: BECKY ROSHAU
Title or Position: OFFICE MANAGER
Credential:
Phone: 701-456-5115