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General NPI Number Information
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NPI Number | 1063722411
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Entity Type | Individual
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Provider Name | SUSAN INGRID BRUEGGEMANN PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 10/19/2010
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 2500 OVERLOOK TER
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City | MADISON
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State | WI
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Zip | 53705-2254
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Country | US
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Telephone | 608-280-7003
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Fax |
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Provider Business Mailing Address
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Address Line | 415 NYGAARD ST
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City | OREGON
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State | WI
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Zip | 53575-1413
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Country | US
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Telephone | 608-445-8606
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 4157
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 1842-029
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License Number State | WI
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