Basic Information
| Provider Information | |||||||||
| NPI: | 1629178256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIELSON | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 S MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583682118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765235 | ||||||||
| FaxNumber: | 7017765297 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583682118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765235 | ||||||||
| FaxNumber: | 7017765297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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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 | 363A00000X | PAC0017 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1456479 | 05 | ND | MEDICAID | N26302 | 01 | ND | BLUE SHIELD | OTHER | N714229 | 01 | ND | MEDICARE PTAN | OTHER |