Healthcare Provider Details

I. General information

NPI: 1750120168
Provider Name (Legal Business Name): JOSHUA DAVID PRUETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 10/04/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10207 CERNY ST # 312B
RALEIGH NC
27617-4879
US

IV. Provider business mailing address

10207 CERNY ST # 312B
RALEIGH NC
27617-4879
US

V. Phone/Fax

Practice location:
  • Phone: 919-660-8346
  • Fax:
Mailing address:
  • Phone: 919-660-8346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-15132
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: