Basic Information
| Provider Information | |||||||||
| NPI: | 1215972872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLGREN | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 W 66TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529200970 | ||||||||
| FaxNumber: | 9529200148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 01/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 1240 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.