Provider Demographics
NPI:1407436199
Name:SPIDAHL, BERIT (PA)
Entity Type:Individual
Prefix:
First Name:BERIT
Middle Name:
Last Name:SPIDAHL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BERIT
Other - Middle Name:
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 E BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-1408
Mailing Address - Country:US
Mailing Address - Phone:218-205-7120
Mailing Address - Fax:
Practice Address - Street 1:209 E BEECH AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1408
Practice Address - Country:US
Practice Address - Phone:218-205-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1182902363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant