Healthcare Provider Details

I. General information

NPI: 1760121180
Provider Name (Legal Business Name): ALEX DANIEL YANISH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

4837 53RD ST S
FARGO ND
58104-4292
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-3241
  • Fax:
Mailing address:
  • Phone: 701-739-4021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberR-1533
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: