Provider Demographics
NPI:1659050060
Name:FOOTE, MYRON ANTHONY
Entity type:Individual
Prefix:
First Name:MYRON
Middle Name:ANTHONY
Last Name:FOOTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 ELBOWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5712
Mailing Address - Country:US
Mailing Address - Phone:701-421-1819
Mailing Address - Fax:
Practice Address - Street 1:1308 ELBOWOOD LN
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5712
Practice Address - Country:US
Practice Address - Phone:701-421-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X
NDFOO601177172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist