Basic Information
| Provider Information | |||||||||
| NPI: | 1164858650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUNIERA | ||||||||
| FirstName: | TIAGO | ||||||||
| MiddleName: | POLESELLI | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 PACES FERRY ROAD SE | ||||||||
| Address2: | SUITE 1-1100 (ATTN: DENISE) | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702713421 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1199 PRINCE AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064751700 | ||||||||
| FaxNumber: | 7064751790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 007644 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.