Provider Demographics
NPI:1477886364
Name:BRUNKOW, KAYLA LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:LYNN
Last Name:BRUNKOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:LYNN
Other - Last Name:STOTESBERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-335-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1086456OtherNCCPA CERTIFICATION NUMBER