Provider Demographics
NPI:1942244876
Name:PRUSSACK, JAMES ANTHONY JR (PT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ANTHONY
Last Name:PRUSSACK
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 HERMES AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1703
Mailing Address - Country:US
Mailing Address - Phone:760-271-3850
Mailing Address - Fax:760-635-0153
Practice Address - Street 1:1070 HERMES AVE
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1703
Practice Address - Country:US
Practice Address - Phone:760-271-3850
Practice Address - Fax:760-635-0153
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272772251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT27277Medicare ID - Type UnspecifiedMED PART B PROVIDER #