Provider Demographics
NPI:1033221411
Name:BRUEFACH, TINA (PA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BRUEFACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3400
Mailing Address - Country:US
Mailing Address - Phone:407-298-6950
Mailing Address - Fax:407-578-2354
Practice Address - Street 1:11140 W COLONIAL DR
Practice Address - Street 2:#3
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3300
Practice Address - Country:US
Practice Address - Phone:407-395-7040
Practice Address - Fax:407-395-7105
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2755363AM0700X
FLPA0002755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00094987OtherRRMCR
FLE2328Medicare ID - Type Unspecified
FLS77020Medicare UPIN