Provider Demographics
NPI:1730436296
Name:VAN DE BOGART, BREANNE (PA-C)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:VAN DE BOGART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:
Other - Last Name:KROGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:701 PARK AVE, R1
Mailing Address - Street 2:HCMC-EMERGENCY DEPT/URGENT CARE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-4342
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE, R1
Practice Address - Street 2:HCMC-EMERGENCY DEPT/URGENT CARE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-1623
Practice Address - Country:US
Practice Address - Phone:612-873-4342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant