MEDICARE: MADISON PRUSS

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	363LF0000X	Family Nurse Practitioner	1034433	TX

General Provider Information

NPI Number	:	1265194641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON PRUSS

Provider Business Mailing Address
First Line	:	4130 N COLLINS ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76005-4547
Country	:	US
Telephone Number	:	817-799-7279
Fax Number	:

Provider Business Practice Location Address
First Line	:	4130 N COLLINS ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76005-4547
Country	:	US
Telephone Number	:	817-799-7273
Fax Number	:

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

Provider Enumeration Date	:	10/12/2021
Last Update Date	:	11/15/2021

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Directions to “ MADISON PRUSS ” Practice Location

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