Basic Information
| Provider Information | |||||||||
| NPI: | 1528136538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DVORAK | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582066002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805345 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S COLUMBIA RD | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805345 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PAC0353 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 11ND1DV | 01 | MN | BCBS MN | OTHER | 27352 | 01 | ND | BCBS ND | OTHER |