Provider Demographics
NPI:1063500841
Name:BRUNNOCK, MEGHAN B (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MEGHAN
Middle Name:B
Last Name:BRUNNOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WATER STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:860-572-9994
Mailing Address - Fax:860-572-9930
Practice Address - Street 1:34 WATER STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355
Practice Address - Country:US
Practice Address - Phone:860-572-9994
Practice Address - Fax:860-572-9930
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS80516Medicare UPIN