Provider Demographics
NPI:1194834291
Name:BRUNER, MELISSA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:BRUNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:THIELE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:6804 CECELIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-4935
Mailing Address - Country:US
Mailing Address - Phone:855-232-0644
Mailing Address - Fax:888-546-0488
Practice Address - Street 1:6804 CECELIA DRIVE
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-4935
Practice Address - Country:US
Practice Address - Phone:855-232-0644
Practice Address - Fax:888-546-0488
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100790363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS69799Medicare UPIN