Basic Information
| Provider Information | |||||||||
| NPI: | 1447475637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GO | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | SO | ||||||||
| NamePrefix: | DR. | ||||||||
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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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 S COLUMBIA RD | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017802300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2007 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4968 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 4968 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD.203611 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 12283 | ND | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 02828387 | 05 | MS | MEDICAID | 2105108 | 05 | LA | MEDICAID |