Healthcare Provider Details

I. General information

NPI: 1114942372
Provider Name (Legal Business Name): KATHLEEN ANN WOOD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 13TH AVE N APT. 310
FARGO ND
58102-2680
US

IV. Provider business mailing address

705 13TH AVE N APT. 310
FARGO ND
58102-2680
US

V. Phone/Fax

Practice location:
  • Phone: 218-779-0533
  • Fax:
Mailing address:
  • Phone: 218-779-0533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4980
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4980
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: