Provider Demographics
NPI:1649565052
Name:BRUNSON, ADRIAN M (PA)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:M
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ADRIAN
Other - Middle Name:M
Other - Last Name:GOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RR 208
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-274-4715
Practice Address - Fax:317-274-2065
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400049092Medicare PIN