Provider Demographics
NPI:1003004318
Name:NORDAHL, GWEN P (PA-C)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:P
Last Name:NORDAHL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 SOUTH CASCADE STREET
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2813
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-736-8757
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8757
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant