Provider Demographics
NPI:1457099772
Name:BRUDENT, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:BRUDENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79922-2040
Mailing Address - Country:US
Mailing Address - Phone:915-540-0805
Mailing Address - Fax:
Practice Address - Street 1:3111 EDGEROCK DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-1524
Practice Address - Country:US
Practice Address - Phone:915-540-0805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171240555253J00000X, 242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL171240555OtherNURSING ADMINISTRATOR