Provider Demographics
NPI:1225032717
Name:BULLERMAN, BRENDA R (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:BULLERMAN
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9556
Mailing Address - Fax:605-328-9501
Practice Address - Street 1:201 MAINE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MN
Practice Address - Zip Code:56110-1214
Practice Address - Country:US
Practice Address - Phone:507-483-2668
Practice Address - Fax:507-483-2925
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0590363AS0400X
MN9095363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6823472Medicaid
SDR04627Medicare UPIN
SD6823472Medicaid
SDS100300Medicare PIN
MN970004156Medicare PIN