Provider Demographics
NPI:1063054039
Name:BRUNKE, HALEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:MARIE
Last Name:BRUNKE
Suffix:
Gender:F
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 1:26444 285TH AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57585-8513
Mailing Address - Country:US
Mailing Address - Phone:605-464-0633
Mailing Address - Fax:
Practice Address - Street 1:161 MAIN ST
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:SD
Practice Address - Zip Code:57555
Practice Address - Country:US
Practice Address - Phone:605-856-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1221363AM0700X
MO2023011685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1221OtherSOUTH DAKOTA BOARD OF MEDICAL AND OSTEOPATHIC EXAMINERS