Provider Demographics
NPI:1326026824
Name:PRUM, ANDRA L (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDRA
Middle Name:L
Last Name:PRUM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5320 S RAINBOW BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1896
Mailing Address - Country:US
Mailing Address - Phone:702-846-5757
Mailing Address - Fax:702-640-5899
Practice Address - Street 1:5320 S RAINBOW BLVD STE 302
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1896
Practice Address - Country:US
Practice Address - Phone:702-846-5757
Practice Address - Fax:702-640-5899
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV1123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCS11196OtherPHARMACY/CDS
NVFP2099441OtherDEA