Provider Demographics
NPI:1881671956
Name:THOMAS-KVIDERA, DEANN (NP)
Entity Type:Individual
Prefix:
First Name:DEANN
Middle Name:
Last Name:THOMAS-KVIDERA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 FRANCE AVE S
Mailing Address - Street 2:SUITE W200
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2163
Mailing Address - Country:US
Mailing Address - Phone:952-924-9005
Mailing Address - Fax:952-924-0330
Practice Address - Street 1:6405 FRANCE AVE S
Practice Address - Street 2:SUITE W200
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2163
Practice Address - Country:US
Practice Address - Phone:952-924-9005
Practice Address - Fax:952-924-0330
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR080809-5363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ22740Medicare UPIN