Healthcare Provider Details

I. General information

NPI: 1508472473
Provider Name (Legal Business Name): CHRISTINE GENEVIEVE HEDSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 05/06/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 2ND AVE
ROLETTE ND
58366
US

IV. Provider business mailing address

PO BOX 356
ROLLA ND
58367-0356
US

V. Phone/Fax

Practice location:
  • Phone: 701-246-3391
  • Fax:
Mailing address:
  • Phone: 763-228-9496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0854
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: