Healthcare Provider Details

I. General information

NPI: 1063017432
Provider Name (Legal Business Name): ETHAN LEE THOMAS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 S. WASHINGTON ST.
GRAND FORKS ND
58201
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-732-7000
  • Fax:
Mailing address:
  • Phone: 701-780-6468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR40656
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: