Provider Demographics
NPI:1770504011
Name:MISLAN, GARRY A (MD)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:A
Last Name:MISLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4528
Mailing Address - Country:US
Mailing Address - Phone:701-642-7000
Mailing Address - Fax:701-642-7055
Practice Address - Street 1:332 2ND AVE N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4528
Practice Address - Country:US
Practice Address - Phone:701-642-7000
Practice Address - Fax:701-642-7055
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38266207Q00000X
ND7247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G12926Medicare UPIN
NDN13503Medicare PIN