Healthcare Provider Details

I. General information

NPI: 1073592077
Provider Name (Legal Business Name): BRYAN P PUCIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 E. MAIN STREET MANKATO CLINIC @ MAIN STREET
MANKATO MN
56002-8674
US

IV. Provider business mailing address

PO BOX 8674 1230 E. MAIN STREET MANKATO CLINIC, LTD
MANKATO MN
56002-8674
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-1811
  • Fax:
Mailing address:
  • Phone: 507-625-1811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53516
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37212
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: