Provider Demographics
NPI:1619288305
Name:BUCHHOLZ, BRENT MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:MICHAEL
Last Name:BUCHHOLZ
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 1:905 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-4334
Mailing Address - Country:US
Mailing Address - Phone:701-683-6400
Mailing Address - Fax:701-683-4345
Practice Address - Street 1:905 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4334
Practice Address - Country:US
Practice Address - Phone:701-683-6400
Practice Address - Fax:701-683-4345
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0428363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454980Medicaid
NDN716033Medicare UPIN