Provider Demographics
NPI:1598705758
Name:QUANRUD, MYRA J (MD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:J
Last Name:QUANRUD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:J
Other - Last Name:HENNESSEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:401 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-4247
Mailing Address - Country:US
Mailing Address - Phone:701-253-5300
Mailing Address - Fax:701-253-5402
Practice Address - Street 1:401 3RD ST SE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4247
Practice Address - Country:US
Practice Address - Phone:701-253-5300
Practice Address - Fax:701-253-5402
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND70000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18047Medicaid
ND772827100Medicaid
NDND100023OtherLHS #
ND12426OtherNDBS #
ND142318OtherUCARE #
NDHP19572OtherHEALTHPARTNERS #
ND14494OtherNDBS #
ND370020540OtherRR MEDICARE #
ND00A25QUOtherMNBS #
ND1201183OtherMEDICA #
ND908075OtherAMERICA'S PPO/ARAZ #
ND5T219QUOtherMNBS #
NDDA9061015621OtherPREFERRED ONE #
ND1201183OtherMEDICA #
NDDA9061015621OtherPREFERRED ONE #