Provider Demographics
NPI:1235219429
Name:BRUMLIK, PETER R (PA, PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:BRUMLIK
Suffix:
Gender:M
Credentials:PA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1567
Mailing Address - Country:US
Mailing Address - Phone:719-380-7210
Mailing Address - Fax:
Practice Address - Street 1:2020 N ACADEMY BLVD
Practice Address - Street 2:SUITE 155
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1567
Practice Address - Country:US
Practice Address - Phone:719-380-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07000102Medicaid
COC481138Medicare ID - Type Unspecified
C481158Medicare PIN
CO07000102Medicaid