Healthcare Provider Details

I. General information

NPI: 1780044362
Provider Name (Legal Business Name): IAN PRUDHOMME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BERGQUIST DR STE 1 WHMC/GE-2200, JBSA LACKLAND AFB, TX
APO AA
78236-5300
US

IV. Provider business mailing address

2200 BERGQUIST DR STE 1 WHMC/GE-2200
JBSA LACKLAND AFB TX
78236-5300
US

V. Phone/Fax

Practice location:
  • Phone: 423-943-2720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number30410
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: