Healthcare Provider Details

I. General information

NPI: 1609867266
Provider Name (Legal Business Name): AARON J PRUSSIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 DAVIS ST SUITE 1
BLACKSBURG VA
24060-7010
US

IV. Provider business mailing address

127 S. 500 E SUITE 600
SALT LAKE CITY UT
84102-1971
US

V. Phone/Fax

Practice location:
  • Phone: 540-381-0344
  • Fax: 540-381-1462
Mailing address:
  • Phone: 801-587-6336
  • Fax: 801-715-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberFP5290337
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number0101051964
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: