Basic Information
| Provider Information | |||||||||
| NPI: | 1023598760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAUNER | ||||||||
| FirstName: | MCKENNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
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| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602662770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 10002592A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.