Provider Demographics
NPI:1891676466
Name:BUGDA, AUTUM
Entity type:Individual
Prefix:
First Name:AUTUM
Middle Name:
Last Name:BUGDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0001
Mailing Address - Country:US
Mailing Address - Phone:570-808-7803
Mailing Address - Fax:570-808-3230
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-808-7803
Practice Address - Fax:570-808-3230
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN009251133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management