Basic Information
| Provider Information | |||||||||
| NPI: | 1265405252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NORBY | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.A-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322874 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 07/13/2012 | ||||||||
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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 | 363AM0700X | 363A00000X | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 8843 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1265405252 | 05 | MN | MEDICAID | 970008760 | 01 | RAILROAD MEDICARE | OTHER | 493982400 | 05 | MN | MEDICAID |