Provider Demographics
NPI:1578766721
Name:BOGNER, BOBBI JO II
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:JO
Last Name:BOGNER
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1132
Mailing Address - Country:US
Mailing Address - Phone:608-884-3441
Mailing Address - Fax:
Practice Address - Street 1:313 STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1132
Practice Address - Country:US
Practice Address - Phone:608-884-3441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1016-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1016-019OtherLICENSE