Provider Demographics
NPI:1326004102
Name:PRUNUSKE, JACOB PAUL (MD, MSPH)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:PAUL
Last Name:PRUNUSKE
Suffix:
Gender:M
Credentials:MD, MSPH
Other - Prefix:
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Mailing Address - Street 1:425 WIND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4149
Mailing Address - Country:US
Mailing Address - Phone:715-675-3391
Mailing Address - Fax:715-675-4253
Practice Address - Street 1:425 WIND RIDGE DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4149
Practice Address - Country:US
Practice Address - Phone:715-675-3391
Practice Address - Fax:715-675-4253
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4979070-1205207Q00000X
WI49598207Q00000X
MN53968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine