Provider Demographics
NPI:1669297776
Name:BRUNGARD, TRISHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:TRISHELLE
Middle Name:
Last Name:BRUNGARD
Suffix:
Gender:F
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 1:15973 ELMWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4250
Mailing Address - Country:US
Mailing Address - Phone:570-939-7294
Mailing Address - Fax:
Practice Address - Street 1:415 17TH AVE N
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-7224
Practice Address - Country:US
Practice Address - Phone:952-931-1276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15085363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant