Basic Information
| Provider Information | |||||||||
| NPI: | 1003337809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANBRUGGEN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 W INNOVATION DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889383838 | ||||||||
| FaxNumber: | 8889191083 | ||||||||
| Practice Location | |||||||||
| Address1: | 4365 PHEASANT RIDGE DR NE STE 106 | ||||||||
| Address2: | |||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554494544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889383838 | ||||||||
| FaxNumber: | 8889191083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2017 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 2017018862 | MO | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 77450 | WI | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 69733 | MN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.