Provider Demographics
NPI:1558382770
Name:STOMPRO, GREGORY P (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:P
Last Name:STOMPRO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 25TH ST S
Mailing Address - Street 2:
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:
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:2006-07-22
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0078363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71055Medicaid
MN382147100Medicaid
ND71055Medicaid
NDN11439Medicare PIN