Provider Demographics
NPI:1811993223
Name:BRUNNER, A MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:A
Middle Name:MATTHEW
Last Name:BRUNNER
Suffix:
Gender:M
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 1:210 VILLAGE CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9044
Mailing Address - Country:US
Mailing Address - Phone:770-474-5952
Mailing Address - Fax:770-474-1300
Practice Address - Street 1:210 VILLAGE CENTER PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9044
Practice Address - Country:US
Practice Address - Phone:770-474-5952
Practice Address - Fax:770-474-1300
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6535OtherKAISER
GAP51724Medicare UPIN
GA97WCCMSMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER