Provider Demographics
NPI:1992757348
Name:FOSSUM, DAVID (PAC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:FOSSUM
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-5672
Mailing Address - Country:US
Mailing Address - Phone:605-891-4839
Mailing Address - Fax:612-725-1318
Practice Address - Street 1:101 MERCURY ST
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-5672
Practice Address - Country:US
Practice Address - Phone:605-891-4839
Practice Address - Fax:605-612-7251
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0413363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6826162Medicaid
SDS67138Medicare UPIN
SDS42409Medicare PIN