Basic Information
| Provider Information | |||||||||
| NPI: | 1073592077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUCIK | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 1230 E. MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC, LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1230 E. MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC @ MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 53516 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 37212 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | HP18443 | 01 | MN | HEALTH PARTNERS | OTHER | 1675630 | 01 | MN | AMERICAS PPO | OTHER | 410849339 56001 C173 | 01 | CHAMPUS | OTHER | NA2951023852 | 01 | MN | PREFERRED ONE | OTHER | 56BO8PU | 01 | MN | BCBS | OTHER | 101792 | 01 | MN | UCARE | OTHER | 805722200 | 05 | MN | MEDICAID | 080159110 | 01 | RR MEDICARE | OTHER | 0118371 | 01 | MN | MEDICA | OTHER |