Provider Demographics
NPI:1891845947
Name:PROCHASKA, VERN JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:VERN
Middle Name:JOHN
Last Name:PROCHASKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 13TH AVE S
Mailing Address - Street 2:SUITE 4-366
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3395
Mailing Address - Country:US
Mailing Address - Phone:701-730-2278
Mailing Address - Fax:
Practice Address - Street 1:600 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1431
Practice Address - Country:US
Practice Address - Phone:218-616-3700
Practice Address - Fax:218-616-3737
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7534174400000X
ND10936207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019809Medicaid
NV002019809Medicaid