Basic Information
| Provider Information | |||||||||
| NPI: | 1982652392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUGGS | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1037 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542203234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206520739 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542203712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 67956-030 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 43403400 | 05 | WI | MEDICAID |