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General NPI Number Information
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NPI Number | 1033563325
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Entity Type | Individual
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Provider Name | NIKOLE LEE KOEHN MATRG, ATC
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Gender | Female
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Dates
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Enumeration Date | 04/22/2016
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Last Update Date | 04/22/2016
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Provider Practice Location Address
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Address Line | 2301 25TH ST S
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City | FARGO
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State | ND
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Zip | 58103
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Country | US
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Telephone | 701-417-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 4551 47TH AVE. SOUTH APT. 103
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City | FARGO
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State | ND
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Zip | 58103
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Country | US
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Telephone | 701-417-6000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2747
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 697-15
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License Number State | ND
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