Healthcare Provider Details

I. General information

NPI: 1881093029
Provider Name (Legal Business Name): TONI RHEAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TONI NELSON

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103-6132
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-8000
  • Fax: 701-364-8078
Mailing address:
  • Phone: 701-364-8000
  • Fax: 701-364-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0573
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberR962
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: