=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326026824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRA L PRUM D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 09/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8905 W POST RD STE 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-660-2024
-----------------------------------------------------
Fax | 701-203-9648
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11700 W CHARLESTON BLVD # 170-597
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89135-1573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-660-2024
-----------------------------------------------------
Fax | 701-203-9648
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 1123
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------