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General NPI Number Information
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NPI Number | 1295940914
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Entity Type | Individual
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Provider Name | REGINA D PRUITT PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 05/17/2022
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Provider Practice Location Address
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Address Line | 5717 21ST AVE W
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City | BRADENTON
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State | FL
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Zip | 34209
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Country | US
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Telephone | 941-792-8383
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Fax | 941-792-8484
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Provider Business Mailing Address
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Address Line | 3300 S FISKE BLVD
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City | ROCKLEDGE
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State | FL
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Zip | 32955-4306
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA.493
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA-493
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License Number State | AL
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9113304
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License Number State | FL
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