Provider Demographics
NPI:1437494879
Name:PRUDHOME, DAVID STEPHEN (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:STEPHEN
Last Name:PRUDHOME
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1908
Mailing Address - Country:US
Mailing Address - Phone:903-597-0351
Mailing Address - Fax:
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-597-0351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX733431367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered