Provider Demographics
NPI:1669854196
Name:STICCA, JONATHAN ALBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ALBERT
Last Name:STICCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1301 NORTH COLUMBIA ROAD
Mailing Address - Street 2:RM E270 STOP 9037
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-9037
Mailing Address - Country:US
Mailing Address - Phone:701-777-2636
Mailing Address - Fax:701-777-3609
Practice Address - Street 1:5225 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7927
Practice Address - Country:US
Practice Address - Phone:701-417-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-20
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15165207Q00000X, 208600000X
SCLL38351207Q00000X
IA46141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine