Healthcare Provider Details

I. General information

NPI: 1093771503
Provider Name (Legal Business Name): JOHN A PRU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PERIMETER DRIVE
ALTA WY
83414
US

IV. Provider business mailing address

PO BOX 563
ALTA WY
83414
US

V. Phone/Fax

Practice location:
  • Phone: 307-421-3396
  • Fax:
Mailing address:
  • Phone: 307-421-3396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6780.0512
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: