Provider Demographics
NPI:1609864180
Name:BRUDER, MARK J (MSN, CRNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BRUDER
Suffix:
Gender:M
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 SHELBYVILLE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2992
Mailing Address - Country:US
Mailing Address - Phone:800-999-1249
Mailing Address - Fax:855-656-7325
Practice Address - Street 1:1620 S. QUEEN ST. STE 2
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4637
Practice Address - Country:US
Practice Address - Phone:800-999-1249
Practice Address - Fax:855-656-7325
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR130259363LF0000X
PAUP005328B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD500014862OtherMEDICARE RR
MDKQ95Medicare PIN
MDS74601Medicare UPIN