Provider Demographics
NPI:1619922531
Name:TRIEBOLD, MARJORIE K (PAC)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:K
Last Name:TRIEBOLD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-253-5300
Mailing Address - Fax:701-253-5402
Practice Address - Street 1:401 3RD ST SE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4247
Practice Address - Country:US
Practice Address - Phone:701-253-5300
Practice Address - Fax:701-253-5402
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0188363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND31Q26TROtherMNBS #
ND540698600Medicaid
NDDA9061015526OtherPREFERRED ONE #
ND142353OtherUCARE #
NDHP38589OtherHEALTHPARTNERS #
ND0111506OtherMEDICA #
ND970005163Medicare ID - Type UnspecifiedRR MEDICARE #
NDDA9061015526OtherPREFERRED ONE #
NDHP38589OtherHEALTHPARTNERS #
ND15511Medicare ID - Type UnspecifiedND MEDICARE #