Provider Demographics
NPI:1245929413
Name:GEORGESON, PAUL KIM
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:KIM
Last Name:GEORGESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 12TH AVE SE LOT 19
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3815
Mailing Address - Country:US
Mailing Address - Phone:507-512-9267
Mailing Address - Fax:
Practice Address - Street 1:817 3RD AVE NE APT 2
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2103
Practice Address - Country:US
Practice Address - Phone:507-216-2448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant