Provider Demographics
NPI:1508416207
Name:BRUNKAN, SHELLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:BRUNKAN
Suffix:
Gender:F
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 1:5725 W LAS POSITAS BLVD STE 100A
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-4054
Mailing Address - Country:US
Mailing Address - Phone:925-734-8130
Mailing Address - Fax:
Practice Address - Street 1:5725 W LAS POSITAS BLVD STE 100A
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-4054
Practice Address - Country:US
Practice Address - Phone:925-734-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-14
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63239363A00000X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty