Provider Demographics
NPI:1184723082
Name:BRUNCK, BRIAN WADE (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WADE
Last Name:BRUNCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:820 S MCCLELLAN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2457
Practice Address - Country:US
Practice Address - Phone:509-838-7100
Practice Address - Fax:509-838-0721
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005071363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8466344Medicaid
WA8466344Medicaid
WA8862026Medicare PIN