Basic Information
| Provider Information | |||||||||
| NPI: | 1134578537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMSON | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
| FaxNumber: | 7017804391 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 7TH STREET NE - ALTRU CLINIC/DEVILS LAKE | ||||||||
| Address2: | |||||||||
| City: | DEVILS LAKE | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583012719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016622157 | ||||||||
| FaxNumber: | 7017804391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RL14150 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 15356 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.