Provider Demographics
NPI:1265470447
Name:BELLANGER-DAHL, JUDY A (PA-C)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:BELLANGER-DAHL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:218-347-4043
Practice Address - Street 1:1000 CONEY ST W
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2102
Practice Address - Country:US
Practice Address - Phone:218-347-1200
Practice Address - Fax:218-347-4043
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9616363AM0700X
ND0325363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
318G9BEOtherMNBCBS
23099OtherNDBCBS
MN924632100Medicaid
23099OtherNDBCBS
MN924632100Medicaid