Healthcare Provider Details

I. General information

NPI: 1255199907
Provider Name (Legal Business Name): ERIC PAUL LEEDAHL RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103-6132
US

IV. Provider business mailing address

4742 51ST ST S
FARGO ND
58104-6016
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-8000
  • Fax:
Mailing address:
  • Phone: 701-866-8763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR46122
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR46122
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR46122
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: