Provider Demographics
NPI:1851440788
Name:BRUK, OLEG (PA)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:BRUK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W END AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1320
Mailing Address - Country:US
Mailing Address - Phone:615-345-5400
Mailing Address - Fax:888-468-6511
Practice Address - Street 1:1600 SARNO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4938
Practice Address - Country:US
Practice Address - Phone:800-348-4565
Practice Address - Fax:888-468-6511
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100709363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291639800Medicaid
FLQ23182Medicare UPIN
FLU3140ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER