Basic Information
Provider Information | |||||||||
NPI: | 1215124573 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KURTZ | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILLIAMS | ||||||||
OtherFirstName: | JULIE | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1720 UNIVERSITY DR S RT 1707 | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581034940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012341728 | ||||||||
FaxNumber: | 7012341681 | ||||||||
Practice Location | |||||||||
Address1: | 2301 25TH ST S | ||||||||
Address2: | SUITE K | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581036104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012341728 | ||||||||
FaxNumber: | 7012341681 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2007 | ||||||||
LastUpdateDate: | 07/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R22570 | ND | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 29117 | 01 | ND | ND BLUE SHIELD | OTHER | 10221 | 05 | ND |   | MEDICAID |