Provider Demographics
NPI:1497427850
Name:BRUNE, ANDREA JAYNE (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JAYNE
Last Name:BRUNE
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 1:9820 BANYAN CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9441
Mailing Address - Country:US
Mailing Address - Phone:260-402-6726
Mailing Address - Fax:
Practice Address - Street 1:7333 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6202
Practice Address - Country:US
Practice Address - Phone:260-458-3825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003380A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant