Provider Demographics
NPI:1407450729
Name:MOFYASANDT, MARTHA (DNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MOFYASANDT
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3728 13TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7442
Mailing Address - Country:US
Mailing Address - Phone:651-815-2408
Mailing Address - Fax:
Practice Address - Street 1:4790 REGENT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2402
Practice Address - Country:US
Practice Address - Phone:877-267-5628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR39541363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care