Provider Demographics
NPI:1184821696
Name:PRUITT, ELIZABETH INEZ (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:INEZ
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16186 MAIN RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:TANGIER
Practice Address - State:VA
Practice Address - Zip Code:23440
Practice Address - Country:US
Practice Address - Phone:757-891-2412
Practice Address - Fax:757-891-2493
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2014-02-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110002506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00616648Medicare PIN
VA1184821696Medicaid
VA017645R53Medicare PIN