Basic Information
| Provider Information | |||||||||
| NPI: | 1689867129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOKSBERGER | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S | ||||||||
| Address2: | PO BOX 1309 MAIL STOP 21110Q | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529938250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 250 CENTRAL AVE N | ||||||||
| Address2: | SUITE 228 | ||||||||
| City: | WAYZATA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553911206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529938250 | ||||||||
| FaxNumber: | 9529938276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2007 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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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 | 207Q00000X | 5101016814 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 107105 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2011-00868 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5919235 | 05 | NC | MEDICAID |