Provider Demographics
NPI:1427439033
Name:BRUNNER, CHARLES (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:BRUNNER
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 1:7210 MCPHERSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6507
Mailing Address - Country:US
Mailing Address - Phone:956-722-8046
Mailing Address - Fax:956-722-8047
Practice Address - Street 1:506 GALE ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6003
Practice Address - Country:US
Practice Address - Phone:956-724-9091
Practice Address - Fax:956-724-8213
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TX443885ZQWQMedicare PIN