Basic Information
| Provider Information | |||||||||
| NPI: | 1710906011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNELLE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 BRIDGEPORT WAY W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535347000 | ||||||||
| FaxNumber: | 2535347099 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 BRIDGEPORT WAY W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535347000 | ||||||||
| FaxNumber: | 2535347099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00032102 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207RH0002X | MD00032102 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1017114 | 05 | WA | MEDICAID |