Healthcare Provider Details

I. General information

NPI: 1265157424
Provider Name (Legal Business Name): VICTORIA JACQUELINE BRUNO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD CONCOURSE LEVEL
PHILADELPHIA PA
19104-5127
US

IV. Provider business mailing address

3400 CIVIC CENTER BLVD CONCOURSE LEVEL
PHILADELPHIA PA
19104-5127
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-3487
  • Fax: 215-349-5534
Mailing address:
  • Phone: 215-662-3487
  • Fax: 215-349-5534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067687
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: