Provider Demographics
NPI:1811456247
Name:BRUNSON, ADAM THOMAS (AG-CNS)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:THOMAS
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:AG-CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 LAVACA ST STE 110-320
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-2172
Mailing Address - Country:US
Mailing Address - Phone:512-477-4088
Mailing Address - Fax:
Practice Address - Street 1:4200 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6060
Practice Address - Country:US
Practice Address - Phone:512-454-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX926072163WG0600X
TXAPI42166364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1376575886Medicaid