Provider Demographics
NPI:1023030517
Name:LUNDEEN, TINA M (NP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:LUNDEEN
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 1:600 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2804
Mailing Address - Country:US
Mailing Address - Phone:701-234-3900
Mailing Address - Fax:701-234-3951
Practice Address - Street 1:600 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2804
Practice Address - Country:US
Practice Address - Phone:701-234-3900
Practice Address - Fax:701-234-3951
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR112247-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S15911Medicare UPIN