Provider Demographics
NPI:1144212507
Name:BRUNER, PAULA CONAWAY (PA)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:CONAWAY
Last Name:BRUNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:ELIZABETH
Other - Last Name:CONAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-341-3321
Practice Address - Street 1:1300 BRIDGE BARRIER RD STE 2
Practice Address - Street 2:
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3939
Practice Address - Country:US
Practice Address - Phone:910-458-4101
Practice Address - Fax:910-458-5617
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2750596EOtherMEDICARE NUMBER
NC2750596AMedicare ID - Type Unspecified
P38936Medicare UPIN