Provider Demographics
NPI:1033302062
Name:FETNER, ERIK GLENN (MD)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:GLENN
Last Name:FETNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-2525
Mailing Address - Fax:701-234-2050
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2525
Practice Address - Fax:701-234-2050
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2328208C00000X
ND11255208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1033302062Medicaid
ND10656Medicaid
TX146851401Medicaid
NDN714342Medicare PIN
TX00967MMedicare PIN
ND10656Medicaid