Provider Demographics
NPI:1356336812
Name:PRUSE, TAMMY G (DO)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:G
Last Name:PRUSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 732892
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2892
Mailing Address - Country:US
Mailing Address - Phone:850-916-3680
Mailing Address - Fax:
Practice Address - Street 1:2115 W NINE MILE RD STE 2
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-9438
Practice Address - Country:US
Practice Address - Phone:850-908-1950
Practice Address - Fax:850-908-1959
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 8320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264519000Medicaid
FLH64411Medicare UPIN
FL264519000Medicaid