Provider Demographics
NPI:1588646970
Name:HERTZENBERG, BRUCE EDWARD (LICENSED SURG ASSIST)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:EDWARD
Last Name:HERTZENBERG
Suffix:
Gender:M
Credentials:LICENSED SURG ASSIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 HOLLY LN N
Mailing Address - Street 2:#3
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-1772
Mailing Address - Country:US
Mailing Address - Phone:763-694-9248
Mailing Address - Fax:763-694-0293
Practice Address - Street 1:5130 HOLLY LN N
Practice Address - Street 2:#3
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-1772
Practice Address - Country:US
Practice Address - Phone:763-694-9248
Practice Address - Fax:763-694-0293
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00271246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN89003OtherCERT. FIRST ASSISTANT
TXSA00271OtherLIC. SURGICAL ASSISTANT
MN066759OtherCERT. SURGICAL TECHNICIAN