Provider Demographics
NPI:1073940219
Name:PRUYN, ROLIN ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ROLIN
Middle Name:ALAN
Last Name:PRUYN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12303 NE 130TH LN
Mailing Address - Street 2:SUITE 550
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3099
Mailing Address - Country:US
Mailing Address - Phone:425-899-6972
Mailing Address - Fax:425-899-6970
Practice Address - Street 1:12303 NE 130TH LN
Practice Address - Street 2:SUITE 550
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3099
Practice Address - Country:US
Practice Address - Phone:425-899-6972
Practice Address - Fax:425-899-6970
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60435739363AM0700X
WI3289-23363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical