Provider Demographics
NPI:1750120168
Name:PRUETT, JOSHUA DAVID
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DAVID
Last Name:PRUETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LAKE DR APT G5
Mailing Address - Street 2:
Mailing Address - City:LAUREL PARK
Mailing Address - State:NC
Mailing Address - Zip Code:28739-4693
Mailing Address - Country:US
Mailing Address - Phone:828-280-3779
Mailing Address - Fax:
Practice Address - Street 1:33 LAKE DR APT G5
Practice Address - Street 2:
Practice Address - City:LAUREL PARK
Practice Address - State:NC
Practice Address - Zip Code:28739-4693
Practice Address - Country:US
Practice Address - Phone:828-280-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program