Healthcare Provider Details

I. General information

NPI: 1174110043
Provider Name (Legal Business Name): PHILLIP BUGANSKI LAT, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 ARCADE ST
VADNAIS HEIGHTS MN
55127-7135
US

IV. Provider business mailing address

4952 EMMIT DR N UNIT 2
HUGO MN
55038-8505
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5200
  • Fax: 651-730-3750
Mailing address:
  • Phone: 763-355-2874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number2389
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: