Provider Demographics
NPI:1083694806
Name:DIMUCCI, MICHAEL V (RN, MSN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:V
Last Name:DIMUCCI
Suffix:
Gender:M
Credentials:RN, MSN, FNP-C
Other - Prefix:
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Mailing Address - Street 1:826 TRENTON LN N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55441-4496
Mailing Address - Country:US
Mailing Address - Phone:612-805-8676
Mailing Address - Fax:249-201-5231
Practice Address - Street 1:423 FORTRESS BLVD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1351
Practice Address - Country:US
Practice Address - Phone:612-805-8676
Practice Address - Fax:249-201-5231
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR 112189-4363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN497460300Medicaid
F0402042OtherAANP BOARD CERTIFICATION
P0825227OtherNAT'L REGISTRY PARAMEDIC
MNR1121894OtherRN LICENSE
MNMD0859415OtherDEA NUMBER
P73851Medicare UPIN
MN50002762Medicare ID - Type Unspecified