Healthcare Provider Details

I. General information

NPI: 1730789900
Provider Name (Legal Business Name): GINA RENAE MATHIASON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA RENAE MARTIN NP-C

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 01/07/2025
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALTRU CANCER CENTER 960 S COLUMBIA ROAD
GRAND FORKS ND
58201
US

IV. Provider business mailing address

PO BOX 13780
GRAND FORKS ND
58208
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5400
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN239823
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201308
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: