Provider Demographics
NPI:1437144938
Name:PRUITT, MARK A (FNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PRUITT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 MAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1369
Mailing Address - Country:US
Mailing Address - Phone:541-632-4050
Mailing Address - Fax:888-377-4656
Practice Address - Street 1:2690 MAY ST STE 102
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-9786
Practice Address - Country:US
Practice Address - Phone:541-632-4050
Practice Address - Fax:888-377-4656
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850048NP363L00000X
TNRN121028363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3902626Medicaid
TN3902628Medicare ID - Type Unspecified
TNS80978Medicare UPIN