Provider Demographics
NPI:1649241845
Name:PRUITT, JOSEPH EDWARD (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EDWARD
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:888-247-0125
Mailing Address - Fax:918-502-8210
Practice Address - Street 1:6151 S YALE AVE STE 100A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1929
Practice Address - Country:US
Practice Address - Phone:918-494-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1274363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200005750AMedicaid
OK20005750AMedicaid
OK300522262OtherMEDICARE GROUP PIN
OKP82980Medicare UPIN