Provider Demographics
NPI:1265194641
Name:PRUSS, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:PRUSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 N COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76005-4547
Mailing Address - Country:US
Mailing Address - Phone:817-799-7279
Mailing Address - Fax:
Practice Address - Street 1:4130 N COLLINS ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76005-4547
Practice Address - Country:US
Practice Address - Phone:817-799-7273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1034433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily