Basic Information
| Provider Information | |||||||||
| NPI: | 1184394660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRANDON TUNSTALL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8025 BLACK HORSE PIKE STE 501 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082322967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098227979 | ||||||||
| FaxNumber: | 6098227980 | ||||||||
| Practice Location | |||||||||
| Address1: | 8025 BLACK HORSE PIKE STE 501 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082322967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098227979 | ||||||||
| FaxNumber: | 6098227980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2021 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | MIKUS | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6098227979 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.