Basic Information
| Provider Information | |||||||||
| NPI: | 1629099858 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSSUM | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346236 | ||||||||
| FaxNumber: | 7012347332 | ||||||||
| Practice Location | |||||||||
| Address1: | 737 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344811 | ||||||||
| FaxNumber: | 7012346979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R25993 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.