Provider Demographics
NPI:1063722411
Name:BRUEGGEMANN, SUSAN INGRID (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:INGRID
Last Name:BRUEGGEMANN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 NYGAARD ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1413
Mailing Address - Country:US
Mailing Address - Phone:608-445-8606
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-280-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1842-029133V00000X
WI4157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered