Provider Demographics
NPI:1407154552
Name:BRUNELL, MICHAEL JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:BRUNELL
Suffix:
Gender:M
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 1:36 BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-3131
Mailing Address - Country:US
Mailing Address - Phone:401-568-7661
Mailing Address - Fax:401-567-0900
Practice Address - Street 1:36 BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859-3131
Practice Address - Country:US
Practice Address - Phone:401-568-7661
Practice Address - Fax:401-567-0900
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPENDING363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical