Provider Demographics
NPI:1083887897
Name:MARK PRUITT FNP PC
Entity Type:Organization
Organization Name:MARK PRUITT FNP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:865-922-4434
Mailing Address - Street 1:8005 WHITESTONE RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37938-3834
Mailing Address - Country:US
Mailing Address - Phone:865-922-4434
Mailing Address - Fax:
Practice Address - Street 1:301 S GALLAHER VIEW RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5355
Practice Address - Country:US
Practice Address - Phone:865-690-0902
Practice Address - Fax:865-690-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-12
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN121028363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNS80978Medicare UPIN