Healthcare Provider Details

I. General information

NPI: 1073092391
Provider Name (Legal Business Name): CHISOM O BRUNS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 MEMORIAL DR
SPRING VALLEY MN
55975-1024
US

IV. Provider business mailing address

2110 FALCON TER NW
STEWARTVILLE MN
55976-1052
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-3443
  • Fax:
Mailing address:
  • Phone: 732-439-2948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12738
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: