Healthcare Provider Details

I. General information

NPI: 1083659106
Provider Name (Legal Business Name): TAMARA ANN PRULL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 N MAIN ST
WELLSVILLE NY
14895-1150
US

IV. Provider business mailing address

3388 RIDGE RD
WILLIAMSON NY
14589-9352
US

V. Phone/Fax

Practice location:
  • Phone: 585-247-6810
  • Fax: 315-589-9406
Mailing address:
  • Phone: 315-589-9657
  • Fax: 315-589-9406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number214246-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: