Healthcare Provider Details

I. General information

NPI: 1316697196
Provider Name (Legal Business Name): TARA JUNE BUGGE RD,LD.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 CLEVELAND AVE N
SAINT PAUL MN
55108-1413
US

IV. Provider business mailing address

3050 EWING AVE S APT 109
MINNEAPOLIS MN
55416-4249
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-5323
  • Fax:
Mailing address:
  • Phone: 218-213-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: