Healthcare Provider Details

I. General information

NPI: 1295940914
Provider Name (Legal Business Name): REGINA D PRUITT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5717 21ST AVE W
BRADENTON FL
34209
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-8383
  • Fax: 941-792-8484
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.493
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-493
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: