Healthcare Provider Details

I. General information

NPI: 1669867420
Provider Name (Legal Business Name): BRANDEN PETRUN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ROCKY MOUNTAIN AVE STE 2200
LOVELAND CO
80538-9004
US

IV. Provider business mailing address

2500 ROCKY MOUNTAIN AVE STE 2200
LOVELAND CO
80538-9004
US

V. Phone/Fax

Practice location:
  • Phone: 970-203-7250
  • Fax:
Mailing address:
  • Phone: 970-203-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number62792
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0066493
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: