Healthcare Provider Details

I. General information

NPI: 1316330350
Provider Name (Legal Business Name): JORDAN ROHRICH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58122-2128
US

IV. Provider business mailing address

1218 COMMANDER DR W
WEST FARGO ND
58078-8454
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2000
  • Fax:
Mailing address:
  • Phone: 701-527-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number79413
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101295
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR35279
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: