Provider Demographics
NPI:1720566847
Name:BRUENJES, LYDIA CHARDEL (PA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:CHARDEL
Last Name:BRUENJES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LYDI
Other - Middle Name:CHARDEL
Other - Last Name:STINAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4110 51ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7776
Practice Address - Country:US
Practice Address - Phone:017-364-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008509363A00000X
MN13972363A00000X
NDPAC0931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant