Provider Demographics
NPI:1902083439
Name:BRUEGGEMAN, MEGAN M (PA)
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:M
Last Name:BRUEGGEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:M
Other - Last Name:PENFOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:500 CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1040
Mailing Address - Fax:906-483-1270
Practice Address - Street 1:500 CAMPUS DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1040
Practice Address - Fax:906-483-1270
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003024363AS0400X
MI5601006262363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003024OtherSTATE LICENSE