Provider Demographics
NPI:1932240025
Name:NORDSTROM, KATHLEEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:NORDSTROM
Suffix:
Gender:F
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:PO BOX 5598
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5598
Mailing Address - Country:US
Mailing Address - Phone:701-222-6100
Mailing Address - Fax:701-222-6150
Practice Address - Street 1:500 N 8TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4445
Practice Address - Country:US
Practice Address - Phone:701-222-6100
Practice Address - Fax:701-222-6150
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND88812085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7704010OtherDR NORDSTROM SD MEDICAID
ND920006668OtherDR NORDSTROM RR MEDICARE
ND11727Medicaid
ND21230OtherDR NORDSTROM BCBS
ND8881OtherSTATE LIC#
ND21230OtherDR NORDSTROM BCBS
ND21230Medicare ID - Type UnspecifiedDR NORDSTROM
ND11727Medicaid
NDN715547Medicare PIN