Provider Demographics
NPI:1720810351
Name:MATUNDULO, BRIANNA TERESE (PA-C)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:TERESE
Last Name:MATUNDULO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:TERESE
Other - Last Name:MARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W204N12570 GOLDENDALE RD
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53076-9769
Mailing Address - Country:US
Mailing Address - Phone:262-423-3820
Mailing Address - Fax:
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6366
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI8069-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720810351Medicaid