1972645117 NPI number — TIMOTHY O PRUETT FNP

Table of content: TIMOTHY O PRUETT FNP (NPI 1972645117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972645117 NPI number — TIMOTHY O PRUETT FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUETT
Provider First Name:
TIMOTHY
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972645117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65801-2580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4620
Provider Business Mailing Address Fax Number:
417-829-4316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 S NATIONAL AVE
Provider Second Line Business Practice Location Address:
SUITE 3600
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-3911
Provider Business Practice Location Address Fax Number:
417-820-3924
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  112446 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 174073 . This is a "MO BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 428328702 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82543 . This is a "ARK BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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