Provider Demographics
NPI:1689160806
Name:BRUNCK, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BRUNCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 ASBURY AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-6171
Mailing Address - Country:US
Mailing Address - Phone:201-562-0040
Mailing Address - Fax:
Practice Address - Street 1:1945 NJ-33
Practice Address - Street 2:
Practice Address - City:NEPTUNE CITY
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-775-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00474300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant