Provider Demographics
NPI:1356562235
Name:KNUDSEN, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:
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 86 SDS 12 2901
Mailing Address - Street 2:
Mailing Address - City:MINNEAOPLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-2901
Mailing Address - Country:US
Mailing Address - Phone:651-968-5050
Mailing Address - Fax:651-968-5900
Practice Address - Street 1:2090 WOODWINDS DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-968-5802
Practice Address - Fax:651-968-5898
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5299OtherLICENSE#