Provider Demographics
NPI:1609938182
Name:STALOCH, COLEEN (PA)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:
Last Name:STALOCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COLEEN
Other - Middle Name:
Other - Last Name:HUMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA, FNP
Mailing Address - Street 1:310 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4515
Mailing Address - Country:US
Mailing Address - Phone:701-530-8800
Mailing Address - Fax:
Practice Address - Street 1:310 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4508
Practice Address - Country:US
Practice Address - Phone:701-530-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR19160363L00000X
NDPAC0041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27445OtherBCBS