Provider Demographics
NPI:1629541172
Name:EVOLVE DERMATOLOGY
Entity Type:Organization
Organization Name:EVOLVE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TINKLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:701-740-0052
Mailing Address - Street 1:1646 28TH AVE. S. #10
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-740-0052
Mailing Address - Fax:
Practice Address - Street 1:401 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4530
Practice Address - Country:US
Practice Address - Phone:701-712-4899
Practice Address - Fax:701-712-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty