Provider Demographics
NPI:1417039991
Name:SPRUELL, ANTHONY EUGENE (PA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:EUGENE
Last Name:SPRUELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660969
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0969
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:2400 S AVENUE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7127
Practice Address - Country:US
Practice Address - Phone:928-336-7100
Practice Address - Fax:928-336-7508
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ160445Medicaid
AZ112339Medicare PIN
AZ160445Medicaid