MEDICARE: CHRISTOPHER RYAN PRUITT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10000646A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000767431	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1356303697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER RYAN PRUITT PA-C

Provider Business Mailing Address
First Line	:	1100 REID PKWY
Second Line	:	MEDICAL STAFF SERVICES
City	:	RICHMOND
State	:	IN
Zip	:	47374-1157
Country	:	US
Telephone Number	:	765-935-8806
Fax Number	:	765-983-3219

Provider Business Practice Location Address
First Line	:	1400 HIGHLAND RD
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-8809
Country	:	US
Telephone Number	:	765-935-8905
Fax Number	:	765-939-4200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	05/18/2021

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