Provider Demographics
NPI:1275124596
Name:BRUNSWICK, DAKOTA GRIFFIN (PA)
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:GRIFFIN
Last Name:BRUNSWICK
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 1:3808 RIVERBEND RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-6822
Mailing Address - Country:US
Mailing Address - Phone:336-905-0685
Mailing Address - Fax:
Practice Address - Street 1:280 EXECUTIVE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1838
Practice Address - Country:US
Practice Address - Phone:237-424-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
NC1010856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)