Provider Demographics
NPI:1003802430
Name:MUIDERMAN, ANTHONY KEVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:KEVIN
Last Name:MUIDERMAN
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 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:701-780-1942
Practice Address - Street 1:3165 DEMERS AVE - TRUYU AESTHETIC CENTER
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-6623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND10458208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34199500Medicaid
WI34199500Medicaid
G13688Medicare UPIN
NDG13688Medicare UPIN
ND712497Medicare PIN