Basic Information
| Provider Information | |||||||||
| NPI: | 1235219429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUMLIK | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | P.A., PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193807210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193807210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 07000102 | 05 | CO | MEDICAID |