Provider Demographics
NPI:1205453420
Name:BRUNNING, SEBASTIAN
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:BRUNNING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 G ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4113
Mailing Address - Country:US
Mailing Address - Phone:541-735-9420
Mailing Address - Fax:
Practice Address - Street 1:1435 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4113
Practice Address - Country:US
Practice Address - Phone:541-735-9420
Practice Address - Fax:541-747-9870
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA201741363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program