1669854196 NPI number — DR. JONATHAN ALBERT STICCA MD

Table of content: DR. JONATHAN ALBERT STICCA MD (NPI 1669854196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669854196 NPI number — DR. JONATHAN ALBERT STICCA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STICCA
Provider First Name:
JONATHAN
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669854196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 NORTH COLUMBIA ROAD
Provider Second Line Business Mailing Address:
RM E270 STOP 9037
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58202-9037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-777-2636
Provider Business Mailing Address Fax Number:
701-777-3609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5225 23RD AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58104-7927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-417-1333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2015

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: 207Q00000X , with the licence number:  15165 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: LL38351 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 46141 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 15165 , 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)