Basic Information
| Provider Information | |||||||||
| NPI: | 1649354150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCKNER | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 110429 | ||||||||
| Address2: | UNIVERSITY PHYSICIANS, INC. | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800420429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034937000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13123 E 16TH AVE | ||||||||
| Address2: | CHILDREN'S HOSPITAL COLORADO | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800457106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207771234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 10/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 37780 | CO | N | Allopathic & Osteopathic Physicians | Dermatology | 207NP0225X | 37780 | CO | Y | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 14651084 | 05 | CO | MEDICAID |