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: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11140 W COLONIAL DR #3
OCOEE FL
34761-3300
US

IV. Provider business mailing address

10000 W COLONIAL DR
OCOEE FL
34761-3400
US

V. Phone/Fax

Practice location:
  • Phone: 407-395-7040
  • Fax: 407-395-7105
Mailing address:
  • Phone: 407-298-6950
  • Fax: 407-578-2354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2755
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0002755
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: