Provider Demographics
NPI:1225472046
Name:DERM ON DEMAND LLC
Entity Type:Organization
Organization Name:DERM ON DEMAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RISA
Authorized Official - Middle Name:ANN ASMUS
Authorized Official - Last Name:DORWEILER
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:763-350-6810
Mailing Address - Street 1:7940 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7169
Mailing Address - Country:US
Mailing Address - Phone:763-350-6810
Mailing Address - Fax:
Practice Address - Street 1:7940 MAIN ST N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7169
Practice Address - Country:US
Practice Address - Phone:763-350-6810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1232822363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN187282600Medicaid
MN187282600Medicaid