Provider Demographics
NPI:1033661244
Name:PRUSINSKI, PHILLIP (FNP)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:PRUSINSKI
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 N 19TH AVE
Mailing Address - Street 2:#6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4602
Mailing Address - Country:US
Mailing Address - Phone:480-607-1124
Mailing Address - Fax:
Practice Address - Street 1:4350 N 19TH AVE
Practice Address - Street 2:#6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4602
Practice Address - Country:US
Practice Address - Phone:480-607-1124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily