Provider Demographics
NPI:1609864180
Name:BRUDER, MARK J (MSN, CRNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BRUDER
Suffix:
Gender:M
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 QUARRY LAKE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3770
Mailing Address - Country:US
Mailing Address - Phone:410-486-2000
Mailing Address - Fax:410-486-0825
Practice Address - Street 1:2800 QUARRY LAKE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3770
Practice Address - Country:US
Practice Address - Phone:410-486-2000
Practice Address - Fax:410-486-0825
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2012-05-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDR130259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD500014862OtherMEDICARE RR
MDKQ95Medicare PIN
MDS74601Medicare UPIN