Provider Demographics
NPI:1326456963
Name:GREAT PLAINS CLINIC, PC
Entity Type:Organization
Organization Name:GREAT PLAINS CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSHAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-456-5115
Mailing Address - Street 1:33 9TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3950
Mailing Address - Country:US
Mailing Address - Phone:701-483-6017
Mailing Address - Fax:701-483-5018
Practice Address - Street 1:33 9TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3950
Practice Address - Country:US
Practice Address - Phone:701-483-6017
Practice Address - Fax:701-483-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty