Provider Demographics
NPI:1144642158
Name:PRUSAK, AMANDA (MA, ATC, LAT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PRUSAK
Suffix:
Gender:F
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 MCFARLAND BLVD E STE 340
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-5882
Mailing Address - Country:US
Mailing Address - Phone:717-309-4662
Mailing Address - Fax:
Practice Address - Street 1:1800 MCFARLAND BLVD E STE 340
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5882
Practice Address - Country:US
Practice Address - Phone:205-345-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2310OtherNORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS
200014240OtherBOARD OF CERTIFICATION