Provider Demographics
NPI:1891705505
Name:BROGHAMMER, LAURIE S (DPM)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:S
Last Name:BROGHAMMER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 MANKATO AVENUE
Mailing Address - Street 2:WINONA CLINIC LTD
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987
Mailing Address - Country:US
Mailing Address - Phone:507-454-3680
Mailing Address - Fax:507-457-7672
Practice Address - Street 1:859 MANKATO AVENUE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-454-3680
Practice Address - Fax:507-457-7672
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN729213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U67301Medicare UPIN