Basic Information
| Provider Information | |||||||||
| NPI: | 1285868901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOLKESTAD | ||||||||
| FirstName: | DYLAN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 415 JEFFERSON ST NORTH | ||||||||
| Address2: | TRI-COUNTY HEALTH CARE | ||||||||
| City: | WADENA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564821296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186313510 | ||||||||
| FaxNumber: | 2186317503 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 DOUGLAS AVE | ||||||||
| Address2: | TRI-COUNTY HEALTH CARE HENNING CLINIC | ||||||||
| City: | HENNING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185832953 | ||||||||
| FaxNumber: | 2185834521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2009 | ||||||||
| LastUpdateDate: | 03/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 52995 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.