Provider Demographics
NPI:1801105531
Name:GREYBULL, IAN L (FNP)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:L
Last Name:GREYBULL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WEST CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503
Mailing Address - Country:US
Mailing Address - Phone:701-323-9900
Mailing Address - Fax:701-323-9911
Practice Address - Street 1:300 WEST CENTURY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-323-9900
Practice Address - Fax:701-323-9911
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR29280363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND000084031Medicaid
NDN716716Medicare PIN