Basic Information
Provider Information | |||||||||
NPI: | 1952572174 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUNNAGE | ||||||||
FirstName: | BRANDON | ||||||||
MiddleName: | BLAINE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 GAGE BLVD | ||||||||
Address2: | STE 101 | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 993529532 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423627 | ||||||||
FaxNumber: | 5096272983 | ||||||||
Practice Location | |||||||||
Address1: | 1100 GOETHALS DRIVE 2ND FLOOR | ||||||||
Address2: | KADLEC CLINIC GENERAL & COLORECTAL SURGERY | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 993523304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423185 | ||||||||
FaxNumber: | 5099461850 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2008 | ||||||||
LastUpdateDate: | 04/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 5101016461 | MI | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | OP60119141 | WA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0261833 | 01 | WA | LABOR & INDUSTRIES | OTHER |