Provider Demographics
NPI:1417964743
Name:GRIENEISEN, BRUNA M (PA)
Entity Type:Individual
Prefix:
First Name:BRUNA
Middle Name:M
Last Name:GRIENEISEN
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:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-0447
Mailing Address - Country:US
Mailing Address - Phone:814-265-8636
Mailing Address - Fax:814-265-8536
Practice Address - Street 1:1200 WOOD ST
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824-2118
Practice Address - Country:US
Practice Address - Phone:814-265-8636
Practice Address - Fax:814-265-8536
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA-052124363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA091946Medicare ID - Type Unspecified
PAP36115Medicare UPIN