Basic Information
| Provider Information | |||||||||
| NPI: | 1467614503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACKERMAN | ||||||||
| FirstName: | WINTER | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | WINTER | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342119 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 332 2ND AVE N | ||||||||
| Address2: | |||||||||
| City: | WAHPETON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580754528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016427000 | ||||||||
| FaxNumber: | 7016427055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11731 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1467614503 | 05 | MN | MEDICAID | 16437 | 05 | ND | MEDICAID |