Basic Information
| Provider Information | |||||||||
| NPI: | 1144354481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WESTERSO | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1213 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015727641 | ||||||||
| FaxNumber: | 7015727710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1213 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015727641 | ||||||||
| FaxNumber: | 7015727710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 0550919 | 05 | MT | MEDICAID |