Provider Demographics
NPI:1730847666
Name:BRUVELIS, STEFAN MORALES (PTA)
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:MORALES
Last Name:BRUVELIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:STEFAN
Other - Middle Name:GUNAR
Other - Last Name:BRUVELIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1507 CENTER ST W
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-0336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1875 19TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1633
Practice Address - Country:US
Practice Address - Phone:507-282-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2436225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant