Provider Demographics
NPI:1194757708
Name:BRUNER, AMY R (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:BRUNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 NW 167TH PL STE 100
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4908
Mailing Address - Country:US
Mailing Address - Phone:503-804-3861
Mailing Address - Fax:503-662-6541
Practice Address - Street 1:1975 NW 167TH PL STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4908
Practice Address - Country:US
Practice Address - Phone:503-804-3861
Practice Address - Fax:503-662-6541
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20343207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150667Medicaid
ORG64479Medicare UPIN
OR100998Medicare ID - Type Unspecified