Basic Information
Provider Information
NPI: 1003004318
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NORDAHL
FirstName: GWEN
MiddleName: P
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 712 SOUTH CASCADE STREET
Address2:  
City: FERGUS FALLS
State: MN
PostalCode: 565372813
CountryCode: US
TelephoneNumber: 2187368000
FaxNumber: 2187368757
Practice Location
Address1: 712 SOUTH CASCADE STREET
Address2:  
City: FERGUS FALLS
State: MN
PostalCode: 565372813
CountryCode: US
TelephoneNumber: 2187368000
FaxNumber: 2187368757
Other Information
ProviderEnumerationDate: 10/11/2007
LastUpdateDate: 07/09/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X1065MNY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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