Healthcare Provider Details

I. General information

NPI: 1104390764
Provider Name (Legal Business Name): NINA MAGDALENA ROBINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 CENTENNIAL BLVD
FARGO ND
58102
US

IV. Provider business mailing address

1837 UNIVERSITY DR N
FARGO ND
58105-2504
US

V. Phone/Fax

Practice location:
  • Phone: 612-708-7434
  • Fax:
Mailing address:
  • Phone: 612-708-7434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2633715
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: