Healthcare Provider Details

I. General information

NPI: 1639803117
Provider Name (Legal Business Name): LISA M JOSTAD APRN,CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 13TH AVE S
FARGO ND
58103-3357
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-6600
  • Fax:
Mailing address:
  • Phone: 701-364-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR29899
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9450
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: