Provider Demographics
NPI:1699218107
Name:PRUGAR, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:PRUGAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 YORK SHORES DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-5371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 LONG SANDS RD
Practice Address - Street 2:SUITE 11
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1158
Practice Address - Country:US
Practice Address - Phone:207-361-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist