Basic Information
| Provider Information | |||||||||
| NPI: | 1982790150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 N NEVADA AVE | ||||||||
| Address2: | STE 4007 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197768500 | ||||||||
| FaxNumber: | 7196341448 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 N NEVADA AVE | ||||||||
| Address2: | STE 4007 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197768500 | ||||||||
| FaxNumber: | 7196341448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 15-02426 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | CO 1391 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | CO1391 | 01 | CO | LICENSE | OTHER |