Provider Demographics
NPI:1053399436
Name:DUPPONG, LINDA (PA-C)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:DUPPONG
Suffix:
Gender:F
Credentials:PA-C
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 640
Mailing Address - Street 2:
Mailing Address - City:GLEN ULLIN
Mailing Address - State:ND
Mailing Address - Zip Code:58631-0640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 ASH AVE
Practice Address - Street 2:
Practice Address - City:GLEN ULLIN
Practice Address - State:ND
Practice Address - Zip Code:58631
Practice Address - Country:US
Practice Address - Phone:701-348-9175
Practice Address - Fax:701-348-9177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPA0021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10485Medicaid
ND10485Medicaid
NDR02344Medicare UPIN