Provider Demographics
NPI:1578598587
Name:MITSKOG, ALISA T (DC)
Entity Type:Individual
Prefix:DR
First Name:ALISA
Middle Name:T
Last Name:MITSKOG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4309
Mailing Address - Country:US
Mailing Address - Phone:701-642-6444
Mailing Address - Fax:701-642-6011
Practice Address - Street 1:319 11TH ST N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4111
Practice Address - Country:US
Practice Address - Phone:701-642-6480
Practice Address - Fax:701-642-6011
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND500111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN922509900Medicaid
ND17175Medicaid
25402Medicare ID - Type Unspecified
ND17175Medicaid