Provider Demographics
NPI:1902861131
Name:BRUNSTAD, JILL K (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:K
Last Name:BRUNSTAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W PINE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-9349
Mailing Address - Country:US
Mailing Address - Phone:715-891-0088
Mailing Address - Fax:
Practice Address - Street 1:302 W PINE ST STE 2
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-9349
Practice Address - Country:US
Practice Address - Phone:715-891-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000611363A00000X
WI2234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759190Medicare PIN