Provider Demographics
NPI:1235103326
Name:VAN BRUNT, PATRICIA JO (PA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JO
Last Name:VAN BRUNT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 E. 72ND STREET
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4913
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-5044
Practice Address - Street 1:159 W. RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:GA
Practice Address - Zip Code:31321-0190
Practice Address - Country:US
Practice Address - Phone:912-653-2897
Practice Address - Fax:912-653-4299
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP00663363AM0700X
GA6037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA006037OtherGEORGIA MEDICAL BOARD
GA006037OtherGEORGIA MEDICAL BOARD
NJP38501Medicare UPIN