Basic Information
| Provider Information | |||||||||
| NPI: | 1730109257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORNACKER | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5501 | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585065501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
| FaxNumber: | 7013235709 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 MANDAN AVE | ||||||||
| Address2: | |||||||||
| City: | MANDAN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585543771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016675000 | ||||||||
| FaxNumber: | 7013238305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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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 | 207Q00000X | 7325 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 18609 | 05 | ND | MEDICAID |