Basic Information
| Provider Information | |||||||||
| NPI: | 1467701847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAHL | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GINGERICH | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 MAIN AVE S | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583682118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765235 | ||||||||
| FaxNumber: | 7017765297 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MAIN AVE S | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583682118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765235 | ||||||||
| FaxNumber: | 7017765297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2012 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R28636 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1452341 | 05 | ND | MEDICAID |