Healthcare Provider Details

I. General information

NPI: 1710238233
Provider Name (Legal Business Name): FARGO PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 20TH ST S
FARGO ND
58104-5917
US

IV. Provider business mailing address

3280 20TH ST S
FARGO ND
58104-5917
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-7408
  • Fax: 701-235-2099
Mailing address:
  • Phone: 701-293-7408
  • Fax: 701-235-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateND

VIII. Authorized Official

Name: JOHN A. G. SAMPSON
Title or Position: OWNER
Credential: MD
Phone: 701-293-7408