Provider Demographics
NPI:1578783171
Name:GRUNDL, BRETT RYAN (MMS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:RYAN
Last Name:GRUNDL
Suffix:
Gender:M
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-1459
Mailing Address - Country:US
Mailing Address - Phone:951-766-2462
Mailing Address - Fax:951-766-2479
Practice Address - Street 1:880 N STATE ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-1459
Practice Address - Country:US
Practice Address - Phone:951-766-2462
Practice Address - Fax:951-766-2479
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 18749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant