Provider Demographics
NPI:1972946036
Name:VAN BRUG, AMY (MT-BC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:VAN BRUG
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2959 CHATHAM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4328
Mailing Address - Country:US
Mailing Address - Phone:908-415-5603
Mailing Address - Fax:
Practice Address - Street 1:2959 CHATHAM ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4328
Practice Address - Country:US
Practice Address - Phone:908-415-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2014-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA09987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist