Provider Demographics
NPI:1588958946
Name:BRUNTZ, ADAM JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JOSEPH
Last Name:BRUNTZ
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 1:929 LIPSCOMB ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-926-2663
Mailing Address - Fax:817-293-8860
Practice Address - Street 1:929 LIPSCOMB ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-926-2663
Practice Address - Fax:817-293-8860
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA07431OtherMEDICAL BOARD LICENSE