Healthcare Provider Details

I. General information

NPI: 1033221411
Provider Name (Legal Business Name): TINA BRUEFACH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/16/2026
Certification Date: 10/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 TUSCOLA BLVD
NORTH PORT FL
34287-2738
US

IV. Provider business mailing address

5616 TUSCOLA BLVD
NORTH PORT FL
34287-2738
US

V. Phone/Fax

Practice location:
  • Phone: 941-240-6273
  • Fax: 941-240-3375
Mailing address:
  • Phone: 941-240-6273
  • Fax: 941-240-3375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2755
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: