Provider Demographics
NPI:1417178443
Name:BRUSS, TODD HAROLD (ATC, LAT, CSCS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:HAROLD
Last Name:BRUSS
Suffix:
Gender:M
Credentials:ATC, LAT, CSCS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:1110 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8306
Practice Address - Country:US
Practice Address - Phone:920-288-5555
Practice Address - Fax:920-288-5550
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3058363A00000X
WI350-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417178443Medicaid
WI71460Medicare PIN
WI07650Medicare PIN