Provider Demographics
NPI:1073092391
Name:BRUNS, CHISOM O (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHISOM
Middle Name:O
Last Name:BRUNS
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 1:2110 FALCON TER NW
Mailing Address - Street 2:
Mailing Address - City:STEWARTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55976-1052
Mailing Address - Country:US
Mailing Address - Phone:732-439-2948
Mailing Address - Fax:
Practice Address - Street 1:802 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55975-1024
Practice Address - Country:US
Practice Address - Phone:507-288-3443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant