Basic Information
| Provider Information | |||||||||
| NPI: | 1164887584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUTSMAN | ||||||||
| FirstName: | KASSANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 TUSCARORA ST | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148011231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075420353 | ||||||||
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| Practice Location | |||||||||
| Address1: | 126 S. CANYON | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756280503 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4722 | NM | Y | Other Service Providers | Specialist | 174400000X | 15811 | NC | N | Other Service Providers | Specialist | 174400000X | 11973 | AZ | N | Other Service Providers | Specialist |
No ID Information.