Healthcare Provider Details

I. General information

NPI: 1356071922
Provider Name (Legal Business Name): JORDAN PHILLIP WURTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 9TH AVE S
FARGO ND
58103-2350
US

IV. Provider business mailing address

2624 9TH AVE S
FARGO ND
58103-2350
US

V. Phone/Fax

Practice location:
  • Phone: 701-298-4500
  • Fax: 701-298-4400
Mailing address:
  • Phone: 701-298-4500
  • Fax: 701-298-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR51654
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: