Provider Demographics
NPI:1518923994
Name:ANVINSON, NICOLE (PA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:ANVINSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 32ND AVE S
Mailing Address - Street 2:STE 202
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6545
Mailing Address - Country:US
Mailing Address - Phone:701-746-6336
Mailing Address - Fax:701-772-1030
Practice Address - Street 1:2424 32ND AVE S
Practice Address - Street 2:STE 202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6545
Practice Address - Country:US
Practice Address - Phone:701-746-6336
Practice Address - Fax:701-772-1030
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9504363A00000X
NDPAC0232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1453358Medicaid
ND18686OtherND BC/BS
MN243620500Medicaid
MN80D90AVOtherMN BC/BS
NDS95096Medicare UPIN
ND1453358Medicaid
MN243620500Medicaid