Healthcare Provider Details

I. General information

NPI: 1972493427
Provider Name (Legal Business Name): ERIC LEE BRUNNER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3056 S KINNICKINNIC AVE
MILWAUKEE WI
53207-2583
US

IV. Provider business mailing address

1688 N FRANKLIN PL
MILWAUKEE WI
53202-2202
US

V. Phone/Fax

Practice location:
  • Phone: 414-326-2660
  • Fax: 414-769-4935
Mailing address:
  • Phone: 507-358-0748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4260-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: