Provider Demographics
NPI:1699755512
Name:PRUYN, LINDSEY M (PA)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:M
Last Name:PRUYN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1647
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1647
Mailing Address - Country:US
Mailing Address - Phone:208-535-4130
Mailing Address - Fax:208-535-4125
Practice Address - Street 1:630 N ARROWLEAF TRL
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-2610
Practice Address - Country:US
Practice Address - Phone:541-549-1318
Practice Address - Fax:541-588-6002
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-462363A00000X
IDPA462363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAUZ8OtherBLUE CROSS
ID80708500Medicaid
ID80708500Medicaid
IDPAUZ8OtherBLUE CROSS