MEDICARE: DR. MADELEINE DISTASO BRUNING NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	269108	CA

General Provider Information

NPI Number	:	1720383391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MADELEINE DISTASO BRUNING NP

Provider Business Mailing Address
First Line	:	1200 N STATE ST
Second Line	:	IRD 116
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-2211
Country	:	US
Telephone Number	:	323-226-5609
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 N STATE ST
Second Line	:	IRD 116
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-2211
Country	:	US
Telephone Number	:	323-226-5609
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2011
Last Update Date	:	01/12/2011

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