Healthcare Provider Details

I. General information

NPI: 1174724116
Provider Name (Legal Business Name): DEREK JOHN LYSTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 S COLUMBIA RD
GRAND FORKS ND
58201-4059
US

IV. Provider business mailing address

PO BOX 6002
GRAND FORKS ND
58206-6002
US

V. Phone/Fax

Practice location:
  • Phone: 701-795-2000
  • Fax: 701-795-2260
Mailing address:
  • Phone: 701-780-5000
  • Fax: 701-780-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11427
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: