Healthcare Provider Details

I. General information

NPI: 1518960095
Provider Name (Legal Business Name): HANNELORE AUGUST BRUCKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W 65TH ST STE 221
MINNEAPOLIS MN
55435-1706
US

IV. Provider business mailing address

7300 FRANCE AVE S SUITE 204
MINNEAPOLIS MN
55435-4525
US

V. Phone/Fax

Practice location:
  • Phone: 952-926-7630
  • Fax: 952-926-2116
Mailing address:
  • Phone: 952-926-7630
  • Fax: 952-926-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number23905
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: