Provider Demographics
NPI:1558174516
Name:AMAGAN, BOBBY R (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:R
Last Name:AMAGAN
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 19TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2925
Mailing Address - Country:US
Mailing Address - Phone:615-524-0861
Mailing Address - Fax:
Practice Address - Street 1:245 PRIOR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5163
Practice Address - Country:US
Practice Address - Phone:615-524-0861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202400001821225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist