Basic Information
| Provider Information | |||||||||
| NPI: | 1649241845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRUITT | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | P.A.- C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10505 E 91ST ST | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741335801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184948500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1274 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 300522262 | 01 | OK | MEDICARE GROUP PIN | OTHER | 20005750A | 05 | OK | MEDICAID |