Provider Demographics
NPI:1306391396
Name:IDEMUDIA, MICHAEL (DNP, APRN, FNP-C)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:IDEMUDIA
Suffix:
Gender:M
Credentials:DNP, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 W MOORE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-3004
Mailing Address - Country:US
Mailing Address - Phone:972-563-1475
Mailing Address - Fax:972-524-5132
Practice Address - Street 1:904 W MOORE AVE STE B
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-3004
Practice Address - Country:US
Practice Address - Phone:972-563-1475
Practice Address - Fax:972-524-5132
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0616821363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370943802Medicaid