Provider Demographics
NPI:1194707745
Name:PRUITT, ANDREW L (PA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:345 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3972
Mailing Address - Country:US
Mailing Address - Phone:303-544-5783
Mailing Address - Fax:303-441-2388
Practice Address - Street 1:311 MAPLETON AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3979
Practice Address - Country:US
Practice Address - Phone:303-544-5700
Practice Address - Fax:303-544-5710
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07178007Medicaid
COS27892Medicare UPIN
CO07178007Medicaid