Provider Demographics
NPI:1811088610
Name:LYSTAD, MARTHA J (NP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:LYSTAD
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:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:
Practice Address - Street 1:19120 200TH ST
Practice Address - Street 2:
Practice Address - City:GREENBUSH
Practice Address - State:MN
Practice Address - Zip Code:56726-9280
Practice Address - Country:US
Practice Address - Phone:218-782-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR114162-5363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner