Healthcare Provider Details

I. General information

NPI: 1205453420
Provider Name (Legal Business Name): SEBASTIAN BRUNNING
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 02/07/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 G ST
SPRINGFIELD OR
97477-4113
US

IV. Provider business mailing address

1435 G ST
SPRINGFIELD OR
97477-4113
US

V. Phone/Fax

Practice location:
  • Phone: 541-735-9420
  • Fax: 541-747-9870
Mailing address:
  • Phone: 541-735-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA201741
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: