Provider Demographics
NPI:1053365957
Name:BRUNS, BRADLEY P (PA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:P
Last Name:BRUNS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41022-0427
Mailing Address - Country:US
Mailing Address - Phone:513-569-6780
Mailing Address - Fax:859-372-0065
Practice Address - Street 1:2408 HILL AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4732
Practice Address - Country:US
Practice Address - Phone:513-569-6780
Practice Address - Fax:859-372-0065
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001078363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00644116OtherRR MEDICARE
S57875Medicare UPIN
OHPA11338Medicare PIN
OHP00644116OtherRR MEDICARE
OHPA11339Medicare PIN
OHPA11337Medicare PIN