Provider Demographics
NPI:1619096609
Name:PRUITT, ALBERTA (PA)
Entity Type:Individual
Prefix:
First Name:ALBERTA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N SAN ANTONIO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1316
Mailing Address - Country:US
Mailing Address - Phone:805-681-5461
Mailing Address - Fax:805-681-5200
Practice Address - Street 1:220 S PALISADE DR
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-8902
Practice Address - Country:US
Practice Address - Phone:805-681-5461
Practice Address - Fax:805-681-5200
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A110490Medicaid
CAPA11049OtherPA LICENSE
CA00A110490Medicaid