Provider Demographics
NPI:1457307217
Name:ROGNLIEN, MICHAEL J (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:ROGNLIEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 25TH ST S
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6104
Mailing Address - Country:US
Mailing Address - Phone:701-237-9712
Mailing Address - Fax:701-237-0922
Practice Address - Street 1:2301 25TH ST S
Practice Address - Street 2:SUITE A
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6104
Practice Address - Country:US
Practice Address - Phone:701-237-9712
Practice Address - Fax:701-237-0922
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NDPAC0239363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15848Medicaid
NDN18876Medicare PIN
NDS97467Medicare UPIN
NDN715653Medicare PIN