Provider Demographics
NPI:1891825733
Name:GOLD, MARYANN (NP)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 9TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3950
Mailing Address - Country:US
Mailing Address - Phone:701-483-6017
Mailing Address - Fax:701-483-5018
Practice Address - Street 1:33 9 ST. WEST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601
Practice Address - Country:US
Practice Address - Phone:701-483-6017
Practice Address - Fax:701-483-5018
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO170319363L00000X
NDR19655363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19931Medicaid
NDN713903Medicare PIN