Provider Demographics
NPI:1063672749
Name:OSTLIE, JANE (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:OSTLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:ND
Mailing Address - Zip Code:58257-1518
Mailing Address - Country:US
Mailing Address - Phone:701-788-4500
Mailing Address - Fax:701-788-4500
Practice Address - Street 1:600 1ST ST SE
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:ND
Practice Address - Zip Code:58257-1518
Practice Address - Country:US
Practice Address - Phone:701-788-4500
Practice Address - Fax:701-788-4500
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11491207Q00000X
NDTRL10930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15151Medicaid