MEDICARE: MR. GREGORY JOHN BRUNSHIDLE AGACNP

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	363LA2100X	Acute Care Nurse Practitioner	11013499	FL

General Provider Information

NPI Number	:	1861060832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY JOHN BRUNSHIDLE AGACNP

Provider Business Mailing Address
First Line	:	PO BOX 142
Second Line	:
City	:	SHARPES
State	:	FL
Zip	:	32959-0142
Country	:	US
Telephone Number	:	321-514-2561
Fax Number	:

Provider Business Practice Location Address
First Line	:	4340 S HOPKINS AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-6689
Country	:	US
Telephone Number	:	321-222-3607
Fax Number	:

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

Provider Enumeration Date	:	06/15/2021
Last Update Date	:	06/15/2021

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