Healthcare Provider Details

I. General information

NPI: 1710898549
Provider Name (Legal Business Name): GAYATRI MISRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4955 30TH AVE S UNIT 306
FARGO ND
58104-8579
US

IV. Provider business mailing address

4955 30TH AVE S UNIT 306
FARGO ND
58104-8579
US

V. Phone/Fax

Practice location:
  • Phone: 701-729-4305
  • Fax:
Mailing address:
  • Phone: 701-729-4305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRL24364
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: