Healthcare Provider Details

I. General information

NPI: 1811334030
Provider Name (Legal Business Name): SHANNON HOLSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 S COLUMBIA RD
GRAND FORKS ND
58201-4059
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201-4183
US

V. Phone/Fax

Practice location:
  • Phone: 701-795-2000
  • Fax: 701-795-2260
Mailing address:
  • Phone: 701-780-4085
  • Fax: 701-780-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14128
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: