Provider Demographics
NPI:1912367293
Name:BUGNI, RYAN (PTA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BUGNI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 E BIG BEAVER RD
Mailing Address - Street 2:STE 200
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2015
Mailing Address - Country:US
Mailing Address - Phone:248-619-1733
Mailing Address - Fax:248-619-1744
Practice Address - Street 1:1819 E BIG BEAVER RD
Practice Address - Street 2:STE 200
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2015
Practice Address - Country:US
Practice Address - Phone:248-619-1733
Practice Address - Fax:248-619-1744
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004841225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236742OtherMEDICARE PROVIDER ID
MI30696OtherBCBS FACILITY ID