Provider Demographics
NPI:1174110043
Name:BUGANSKI, PHILLIP (LAT, OTC)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BUGANSKI
Suffix:
Gender:M
Credentials:LAT, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4952 EMMIT DR N UNIT 2
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-8505
Mailing Address - Country:US
Mailing Address - Phone:763-355-2874
Mailing Address - Fax:
Practice Address - Street 1:3580 ARCADE ST
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-7135
Practice Address - Country:US
Practice Address - Phone:651-968-5200
Practice Address - Fax:651-730-3750
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2389247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2389OtherLICENSE