Basic Information
| Provider Information | |||||||||
| NPI: | 1033661244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRUSINSKI | ||||||||
| FirstName: | PHILLIP | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4350 N 19TH AVE | ||||||||
| Address2: | #6 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850154602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806071124 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4350 N 19TH AVE | ||||||||
| Address2: | #6 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850154602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806071124 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP9609 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.