Healthcare Provider Details

I. General information

NPI: 1063722411
Provider Name (Legal Business Name): SUSAN INGRID BRUEGGEMANN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

IV. Provider business mailing address

415 NYGAARD ST
OREGON WI
53575-1413
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-7003
  • Fax:
Mailing address:
  • Phone: 608-445-8606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4157
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1842-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: