1215124573 NPI number — JULIE ANN KURTZ CRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215124573 NPI number — JULIE ANN KURTZ CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KURTZ
Provider First Name:
JULIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS
Provider Other First Name:
JULIE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215124573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 UNIVERSITY DR S RT 1707
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-4940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-234-1728
Provider Business Mailing Address Fax Number:
701-234-1681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 25TH ST S
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-234-1728
Provider Business Practice Location Address Fax Number:
701-234-1681
Provider Enumeration Date:
10/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R22570 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 29117 . This is a "ND BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 10221 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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