Healthcare Provider Details

I. General information

NPI: 1285100834
Provider Name (Legal Business Name): MATTHEW JAMES BRUNELLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HURON RIVER DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

150 BURWYCK PARK DR
SALINE MI
48176-8742
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3456
  • Fax:
Mailing address:
  • Phone: 419-291-4491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704266794
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number019772
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.019772
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: