Provider Demographics
NPI:1144604158
Name:AZURE BEARSTAIL, BRITTANY (MD)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:AZURE BEARSTAIL
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 1:701 E ROSSER AVE.
Mailing Address - Street 2:
Mailing Address - City:BISMARK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4461
Mailing Address - Country:US
Mailing Address - Phone:701-751-9500
Mailing Address - Fax:701-751-9508
Practice Address - Street 1:10 N RIVER ROAD
Practice Address - Street 2:
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58537
Practice Address - Country:US
Practice Address - Phone:701-854-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT15339207Q00000X
NDRL13781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12083Medicaid
ND12083Medicaid