Provider Demographics
NPI:1104890839
Name:BRUNK, JARED L (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:L
Last Name:BRUNK
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 JUPITER LAKES BLVD.
Mailing Address - Street 2:STE. 5105
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458
Mailing Address - Country:US
Mailing Address - Phone:561-748-4445
Mailing Address - Fax:561-748-4449
Practice Address - Street 1:210 JUPITER LAKES BLVD
Practice Address - Street 2:STE. 5105
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7191
Practice Address - Country:US
Practice Address - Phone:561-748-4445
Practice Address - Fax:561-748-4449
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103230363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6029ZMedicare PIN
FLQ52934Medicare UPIN