Healthcare Provider Details

I. General information

NPI: 1053399436
Provider Name (Legal Business Name): LINDA DUPPONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 ASH AVE
GLEN ULLIN ND
58631
US

IV. Provider business mailing address

PO BOX 640
GLEN ULLIN ND
58631-0640
US

V. Phone/Fax

Practice location:
  • Phone: 701-348-9175
  • Fax: 701-348-9177
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0021
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: