Basic Information
| Provider Information | |||||||||
| NPI: | 1700023512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUGAN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 618 14TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | DEVILS LAKE | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583012808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015447000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PAC0407 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PAC0407 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1454377 | 05 | ND | MEDICAID |