Provider Demographics
NPI:1881101178
Name:BRONNENBERG, MICHAEL PHILIP (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILIP
Last Name:BRONNENBERG
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 1:53 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHICHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03258-6509
Mailing Address - Country:US
Mailing Address - Phone:603-897-9128
Mailing Address - Fax:
Practice Address - Street 1:250 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7539
Practice Address - Country:US
Practice Address - Phone:603-227-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPENDING363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical