Provider Demographics
NPI:1073592077
Name:PUCIK, BRYAN P (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:P
Last Name:PUCIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8674 1230 E. MAIN STREET
Mailing Address - Street 2:MANKATO CLINIC, LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E. MAIN STREET
Practice Address - Street 2:MANKATO CLINIC @ MAIN STREET
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53516207Q00000X
MN37212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP18443OtherHEALTH PARTNERS
MN1675630OtherAMERICAS PPO
410849339 56001 C173OtherCHAMPUS
MNNA2951023852OtherPREFERRED ONE
MN56BO8PUOtherBCBS
MN101792OtherUCARE
MN805722200Medicaid
080159110OtherRR MEDICARE
MN0118371OtherMEDICA
MN101792OtherUCARE
MNNA2951023852OtherPREFERRED ONE