Provider Demographics
NPI:1740241140
Name:PRUSAK, TISHA (CRNA MS)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:PRUSAK
Suffix:
Gender:F
Credentials:CRNA MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 E. HURON RIVER DRIVE
Mailing Address - Street 2:DEPT OF ANESTHESIOLOGY
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106
Mailing Address - Country:US
Mailing Address - Phone:734-712-3840
Mailing Address - Fax:
Practice Address - Street 1:5301 E HURON RIVER DR
Practice Address - Street 2:DEPT OF ANESTHESIOLOGY
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3840
Practice Address - Fax:734-712-5526
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704207329367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered