Healthcare Provider Details

I. General information

NPI: 1609864180
Provider Name (Legal Business Name): MARK J BRUDER MSN, CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 S. QUEEN ST. STE 2
YORK PA
17403-4637
US

IV. Provider business mailing address

9800 SHELBYVILLE RD STE 220
LOUISVILLE KY
40223-2992
US

V. Phone/Fax

Practice location:
  • Phone: 800-999-1249
  • Fax: 855-656-7325
Mailing address:
  • Phone: 800-999-1249
  • Fax: 855-656-7325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR130259
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberUP005328B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: