Provider Demographics
NPI:1194720797
Name:PRUCINSKY, CAITLYN G (PA)
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:G
Last Name:PRUCINSKY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CAITLYN
Other - Middle Name:GRAHAM
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 SE MONTEREY RD STE 400
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4512
Practice Address - Country:US
Practice Address - Phone:772-288-2400
Practice Address - Fax:772-419-0144
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA111020363A00000X
FLPA91111020363A00000X
IN10000698A363AM0700X, 363AS0400X
IN10000698363AS0400X
FLPA9111020363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430017Medicare PIN
061570ZZMedicare PIN
Q33422Medicare UPIN