Basic Information
| Provider Information | |||||||||
| NPI: | 1063556652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 997 | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585020997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 E BROADWAY AVENUE | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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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 | R16331 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1454252 | 05 | ND | MEDICAID | 500030678 | 01 | ND | RR MEDICARE | OTHER | R16331 | 01 | ND | LICENSE | OTHER | 22998 | 01 | ND | BCBS ND | OTHER |