Provider Demographics
NPI:1174838650
Name:AWAH, DISA LG (DO)
Entity Type:Individual
Prefix:
First Name:DISA
Middle Name:LG
Last Name:AWAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DISA
Other - Middle Name:L
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-857-5650
Mailing Address - Fax:701-854-5031
Practice Address - Street 1:400 BURDICK EXPY E
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4768
Practice Address - Country:US
Practice Address - Phone:701-857-7969
Practice Address - Fax:701-857-7957
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND13345207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND81339Medicaid
ND81339Medicaid