Provider Demographics
NPI:1386280261
Name:CANOPY MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:CANOPY MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:SELZLER-ECHOLA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:701-264-5200
Mailing Address - Street 1:1411 32ND ST S STE 1
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6304
Mailing Address - Country:US
Mailing Address - Phone:701-264-5200
Mailing Address - Fax:
Practice Address - Street 1:1411 32ND ST S STE 1
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6304
Practice Address - Country:US
Practice Address - Phone:701-306-0943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-26
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty