Provider Demographics
NPI:1407154552
Name:BRUNELL, MICHAEL JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:BRUNELL
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 1:101 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1101
Mailing Address - Country:US
Mailing Address - Phone:508-425-5050
Mailing Address - Fax:508-556-6155
Practice Address - Street 1:101 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1101
Practice Address - Country:US
Practice Address - Phone:508-425-5050
Practice Address - Fax:508-556-6155
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6950363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110151149AMedicaid