Provider Demographics
NPI:1356336812
Name:PRUSE, TAMMY G (DO)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:G
Last Name:PRUSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95590
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0590
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-7976
Practice Address - Street 1:3874 HIGHWAY 90 STE 101
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1014
Practice Address - Country:US
Practice Address - Phone:850-908-2315
Practice Address - Fax:850-908-2307
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 8320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264519000Medicaid
FLH64411Medicare UPIN
FL264519000Medicaid