MEDICARE: AMBER DAWN BRUENS PA-C

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	363A00000X	Physician Assistant	PA9106697	FL

General Provider Information

NPI Number	:	1922354315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER DAWN BRUENS PA-C

Provider Business Mailing Address
First Line	:	4371 VERONICA S SHOEMAKER BLVD
Second Line	:	ATTN: CREDENTIALING DEPARTMENT
City	:	FORT MYERS
State	:	FL
Zip	:	33916-2216
Country	:	US
Telephone Number	:	239-274-8200
Fax Number	:	239-278-3350

Provider Business Practice Location Address
First Line	:	2501 N ORANGE AVE
Second Line	:	SUITE 381
City	:	ORLANDO
State	:	FL
Zip	:	32804-4623
Country	:	US
Telephone Number	:	407-898-5452
Fax Number	:	407-894-1183

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

Provider Enumeration Date	:	08/03/2012
Last Update Date	:	09/10/2015

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