Healthcare Provider Details

I. General information

NPI: 1124045760
Provider Name (Legal Business Name): MARGARET TRAYNOR MICKELSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

801 BROADWAY N
FARGO ND
58102-3641
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2241
  • Fax: 701-234-4877
Mailing address:
  • Phone: 701-234-2241
  • Fax: 701-234-4877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number7965
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: