Provider Demographics
NPI:1265405849
Name:BRUNER, LIA P (MD)
Entity type:Individual
Prefix:
First Name:LIA
Middle Name:P
Last Name:BRUNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIA
Other - Middle Name:S
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 48089
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8089
Mailing Address - Country:US
Mailing Address - Phone:706-389-3727
Mailing Address - Fax:706-389-3951
Practice Address - Street 1:1500 OGLETHORPE AVE STE 200C
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2165
Practice Address - Country:US
Practice Address - Phone:706-389-3875
Practice Address - Fax:706-389-3876
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA77566207Q00000X
VA0101245828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1265405849Medicaid
VA1265405849Medicaid
VA021972B28Medicare PIN