Provider Demographics
NPI:1982621454
Name:KJOS, VICKI L (PA-C)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:KJOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:L
Other - Last Name:PAULSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-4222
Mailing Address - Fax:
Practice Address - Street 1:3902 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-364-6600
Practice Address - Fax:701-364-6628
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5243363AM0700X
MN9326363A00000X
ND0224363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ744746Medicaid
ND713085Medicare PIN
S54131Medicare UPIN
AZ744746Medicaid
AZZ91380Medicare PIN