Healthcare Provider Details

I. General information

NPI: 1184923179
Provider Name (Legal Business Name): ALISA T MITSKOG, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 11TH ST N
WAHPETON ND
58075-4111
US

IV. Provider business mailing address

PO BOX 1461
WAHPETON ND
58074-1461
US

V. Phone/Fax

Practice location:
  • Phone: 701-642-6444
  • Fax:
Mailing address:
  • Phone: 701-642-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number500
License Number StateND

VIII. Authorized Official

Name: DR. ALISA T MITSKOG
Title or Position: PRESIDENT
Credential: DC
Phone: 701-642-6444