Provider Demographics
NPI:1205159803
Name:BRUGGER, MAKELL (CST)
Entity type:Individual
Prefix:
First Name:MAKELL
Middle Name:
Last Name:BRUGGER
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 E RIVERSIDE DR
Mailing Address - Street 2:SUITE 234
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6864
Mailing Address - Country:US
Mailing Address - Phone:208-938-4080
Mailing Address - Fax:208-938-8922
Practice Address - Street 1:323 E RIVERSIDE DR
Practice Address - Street 2:SUITE 234
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6864
Practice Address - Country:US
Practice Address - Phone:208-938-4080
Practice Address - Fax:208-938-8922
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID96662246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist