Provider Demographics
NPI:1730789900
Name:MATHIASON, GINA RENAE (NP-C)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:RENAE
Last Name:MATHIASON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:RENAE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 13780
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:ALTRU CANCER CENTER
Practice Address - Street 2:960 S COLUMBIA ROAD
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239823363L00000X
ND201308363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner