Healthcare Provider Details

I. General information

NPI: 1023390507
Provider Name (Legal Business Name): TRICIA M MIEDEMA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ADAMS ST
AFTON WY
83110-9621
US

IV. Provider business mailing address

901 ADAMS ST
AFTON WY
83110-9621
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-5800
  • Fax:
Mailing address:
  • Phone: 307-885-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR79477
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006114
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberTL8682
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: