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General NPI Number Information
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NPI Number | 1114160215
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Entity Type | Individual
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Provider Name | MICHAEL RYAN BRUNSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/20/2009
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Last Update Date | 06/30/2022
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Provider Practice Location Address
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Address Line | 35TH MDG UNIT 5024
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City | APO
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State | AP
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Zip | 96319
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Country | US
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Telephone | 315-226-6495
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Fax |
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Provider Business Mailing Address
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Address Line | 4102 PINION DRIVE, 10TH MEDICAL GROUP
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City | USAF ACADEMY
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State | CO
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Zip | 80840-2502
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Country | US
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Telephone | 719-333-3717
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 26095
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License Number State | NE
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Taxonomy #3
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 26095
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License Number State | NE
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