Healthcare Provider Details

I. General information

NPI: 1972176477
Provider Name (Legal Business Name): LISA MARIE GIESEKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 23RD AVE S
FARGO ND
58104-7927
US

IV. Provider business mailing address

5868 63RD AVE S
FARGO ND
58104-5684
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-2000
  • Fax:
Mailing address:
  • Phone: 507-276-0757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR49823
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR49823
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2804
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: