Healthcare Provider Details

I. General information

NPI: 1053873802
Provider Name (Legal Business Name): MATTHEW THOMAS OLIPHANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date: 02/25/2020
Reactivation Date: 07/23/2020

III. Provider practice location address

1720 SOUTH UNIVERSITY HOSPITAL
FARGO ND
58103
US

IV. Provider business mailing address

3223 32ND AVE S
FARGO ND
58103-6297
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number940-22
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: