Provider Demographics
NPI:1932308392
Name:PRITT, AUDRA L (MD)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:L
Last Name:PRITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:L
Other - Last Name:BANNISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 MEDICAL CENTER DRIVE, STE 3500
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701
Mailing Address - Country:US
Mailing Address - Phone:304-691-1300
Mailing Address - Fax:304-691-1375
Practice Address - Street 1:1600 MEDICAL CENTER DRIVE, STE 3500
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3655
Practice Address - Country:US
Practice Address - Phone:304-691-1300
Practice Address - Fax:304-691-1375
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24034208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810017793Medicaid
WV3810017793Medicaid