MEDICARE: THERESE A BUGAJ APN-CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	041-144120	IL
2	367500000X	Certified Registered Nurse Anesthetist	209000530	IL

General Provider Information

NPI Number	:	1770580946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESE A BUGAJ APN-CRNA

Provider Business Mailing Address
First Line	:	1174 OAK KNOLL DR
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-3648
Country	:	US
Telephone Number	:	847-234-0045
Fax Number	:

Provider Business Practice Location Address
First Line	:	18221 TORRENCE AVE
Second Line	:	SUITE 1-D
City	:	LANSING
State	:	IL
Zip	:	60438-2870
Country	:	US
Telephone Number	:	708-895-9450
Fax Number	:	847-895-9455

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2005
Last Update Date	:	11/01/2024

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