Provider Demographics
NPI:1669867420
Name:PETRUN, BRANDEN
Entity type:Individual
Prefix:
First Name:BRANDEN
Middle Name:
Last Name:PETRUN
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 1:2500 ROCKY MOUNTAIN AVE STE 2200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9004
Mailing Address - Country:US
Mailing Address - Phone:970-203-7250
Mailing Address - Fax:
Practice Address - Street 1:2500 ROCKY MOUNTAIN AVE STE 2200
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9004
Practice Address - Country:US
Practice Address - Phone:970-203-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN62792208600000X
390200000X
CODR.0066493208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program