Provider Demographics
NPI:1083659106
Name:PRULL, TAMARA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:ANN
Last Name:PRULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3388 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9352
Mailing Address - Country:US
Mailing Address - Phone:315-589-9657
Mailing Address - Fax:315-589-9406
Practice Address - Street 1:191 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1150
Practice Address - Country:US
Practice Address - Phone:585-247-6810
Practice Address - Fax:315-589-9406
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214246-1207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00203836OtherRRM LEGACY
NYP00393355OtherRAILROAD
NY02390949Medicaid
NY000527179003OtherBCBS
NY000527179003OtherBCBS
NYP00393355OtherRAILROAD