Provider Demographics
NPI:1538147533
Name:PRUETT, MICHELLE ANTOINETTE (PA C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANTOINETTE
Last Name:PRUETT
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 EIGER RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8976
Mailing Address - Country:US
Mailing Address - Phone:512-892-7076
Mailing Address - Fax:512-899-8460
Practice Address - Street 1:5625 EIGER RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8976
Practice Address - Country:US
Practice Address - Phone:512-892-7076
Practice Address - Fax:512-899-8460
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1050570OtherNATL COMMISSION PA CERTIF