Provider Demographics
NPI:1255348389
Name:PRUITT, KRISTINE L (PA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:L
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:MCHENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:317 N FM 1187
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-4200
Mailing Address - Country:US
Mailing Address - Phone:817-441-7181
Mailing Address - Fax:817-441-7893
Practice Address - Street 1:317 N FM 1187
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-4200
Practice Address - Country:US
Practice Address - Phone:817-441-7181
Practice Address - Fax:817-441-7893
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184064701Medicaid
TX8G8864Medicare PIN
TXTXB126177Medicare PIN
TXTXB126178Medicare PIN
TX184064701Medicaid
TXTXB126179Medicare PIN