Provider Demographics
NPI:1629800032
Name:PRUITT, CHRISTOPHER (PA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:PRUITT
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 1:1300 VENTURE WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4353
Mailing Address - Country:US
Mailing Address - Phone:307-268-9904
Mailing Address - Fax:
Practice Address - Street 1:1300 VENTURE WAY STE 206
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4353
Practice Address - Country:US
Practice Address - Phone:307-268-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1408363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical