Healthcare Provider Details

I. General information

NPI: 1407450729
Provider Name (Legal Business Name): MARTHA MOFYASANDT DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2020
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FARGO VA, 2101 ELM STREET N
FARGO ND
58102
US

IV. Provider business mailing address

3728 13TH ST S
MOORHEAD MN
56560-7442
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax: 701-237-2623
Mailing address:
  • Phone: 651-815-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR39541
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: