Provider Demographics
NPI:1023475878
Name:PRUITT, MATTHEW H (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:H
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:27 LARIAT CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4142
Mailing Address - Country:US
Mailing Address - Phone:407-625-4547
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3353
Practice Address - Country:US
Practice Address - Phone:501-776-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant