Healthcare Provider Details

I. General information

NPI: 1427276260
Provider Name (Legal Business Name): KINSEY BJORN NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 21ST AVE S
FARGO ND
58103-5759
US

IV. Provider business mailing address

1800 21ST AVE S
FARGO ND
58103-5759
US

V. Phone/Fax

Practice location:
  • Phone: 701-365-8700
  • Fax: 701-365-8701
Mailing address:
  • Phone: 701-365-8700
  • Fax: 701-365-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12048
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51215
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPT 12048
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: