Basic Information
| Provider Information | |||||||||
| NPI: | 1982613246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOVERSON SCHOTT | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOVERSON | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582066002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805000 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 SOUTH COLUMBIA ROAD | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582066002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805000 | ||||||||
| FaxNumber: | 7017801942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 48913 | MN | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 40404 | AZ | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 11319 | ND | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | MN-48913 | MN | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | P00610304 | 01 | MN | RAILROAD MEDICARE | OTHER | 350219 | 05 | AZ | MEDICAID | P00624826 | 01 | AZ | RAILROAD MEDICARE | OTHER | 228673100 | 05 | MN | MEDICAID |