MEDICARE: ROSEANN PRUITT PA-C, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT001944	GA
2	363A00000X	Physician Assistant		GA
3	363AM0700X	Medical Physician Assistant	9174	GA

General Provider Information

NPI Number	:	1114304284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSEANN PRUITT PA-C, ATC

Provider Business Mailing Address
First Line	:	169 REDTAIL RD
Second Line	:
City	:	JEFFERSON
State	:	GA
Zip	:	30549-7070
Country	:	US
Telephone Number	:	978-618-7329
Fax Number	:

Provider Business Practice Location Address
First Line	:	1762 CLIFTON RD NE
Second Line	:	STE 1650
City	:	ATLANTA
State	:	GA
Zip	:	30322-4001
Country	:	US
Telephone Number	:	978-618-7329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2015
Last Update Date	:	03/10/2019

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