Provider Demographics
NPI:1356310064
Name:PRUDDEN, GEORGE A (PA-C)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name:PRUDDEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9084 SE WILLOCK RD STE 201
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9660
Mailing Address - Country:US
Mailing Address - Phone:253-576-7353
Mailing Address - Fax:
Practice Address - Street 1:7308 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8000
Practice Address - Country:US
Practice Address - Phone:253-582-7257
Practice Address - Fax:253-582-1617
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004097363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6882PROtherREGENCE BLUE SHIELD RIDER
WA8348963Medicaid
WA6882PROtherREGENCE BLUE SHIELD RIDER
WAR22743Medicare UPIN