Basic Information
| Provider Information | |||||||||
| NPI: | 1972534642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOFSOMMER | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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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 | 213E00000X | 15 | ND | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 2700488 | 01 | ND | MEDICA # | OTHER | 41093 | 01 | ND | LHS # | OTHER | 593525300 | 05 | ND | MEDICAID | 117307 | 01 | ND | UCARE # | OTHER | 15387 | 05 | ND | MEDICAID | HP21437 | 01 | ND | HEALTHPARTNERS # | OTHER | 20314 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | 25446 | 01 | ND | NDBS # | OTHER | DA9011008260 | 01 | ND | PREFERRED ONE # | OTHER | 2700493 | 01 | ND | MEDICA # | OTHER | 466L6HO | 01 | ND | MNBS # | OTHER |