Provider Demographics
NPI:1699704726
Name:ABRAHAMSON, PHYLLIS
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:ABRAHAMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4996
Mailing Address - Country:US
Mailing Address - Phone:701-751-3050
Mailing Address - Fax:701-751-3053
Practice Address - Street 1:201 N 24TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4996
Practice Address - Country:US
Practice Address - Phone:701-751-3050
Practice Address - Fax:701-751-3053
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN27107OtherBLUE SHIELD
NDN27107OtherBLUE SHIELD