Provider Demographics
NPI:1720026768
Name:WITZEL, GWEN (NP-C)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:WITZEL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:ROHDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-2484
Mailing Address - Country:US
Mailing Address - Phone:701-234-2000
Mailing Address - Fax:701-417-3726
Practice Address - Street 1:5225 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7927
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR22146363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19584Medicaid
ND19584Medicaid
ND15155Medicare ID - Type Unspecified