Healthcare Provider Details

I. General information

NPI: 1437144938
Provider Name (Legal Business Name): MARK A PRUITT FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DOCTORS PARK
GALAX VA
24333-2277
US

IV. Provider business mailing address

101 DOCTORS PARK
GALAX VA
24333-2277
US

V. Phone/Fax

Practice location:
  • Phone: 541-632-4050
  • Fax: 276-883-6232
Mailing address:
  • Phone: 276-595-8921
  • Fax: 276-883-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number7012
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024178316
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: