Healthcare Provider Details

I. General information

NPI: 1710904487
Provider Name (Legal Business Name): JEFFREY K LYSTAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 25TH ST S
FARGO ND
58103-6104
US

IV. Provider business mailing address

2301 25TH ST S
FARGO ND
58103-6104
US

V. Phone/Fax

Practice location:
  • Phone: 701-237-9712
  • Fax:
Mailing address:
  • Phone: 701-237-9712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number7448
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: