Healthcare Provider Details

I. General information

NPI: 1891881116
Provider Name (Legal Business Name): RIO D SILVERNAIL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 SOUTH COLUMBIA ROAD STE A #131
GRAND FORKS ND
58206-6002
US

IV. Provider business mailing address

PO BOX 6002 STE A #131
GRAND FORKS ND
58206-6002
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5000
  • Fax:
Mailing address:
  • Phone: 701-780-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0447
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01305
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60193517
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number924
License Number StateAK
# 5
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP00049977
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: