Healthcare Provider Details

I. General information

NPI: 1164737417
Provider Name (Legal Business Name): NICHOLAS JAMES PRUETT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 W 81ST ST STE 112
BLOOMINGTON MN
55437-1111
US

IV. Provider business mailing address

4801 W 81ST ST STE 112
BLOOMINGTON MN
55437-1111
US

V. Phone/Fax

Practice location:
  • Phone: 952-345-3000
  • Fax: 952-345-6789
Mailing address:
  • Phone: 952-345-3000
  • Fax: 952-345-6789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10813
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10813
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: