Basic Information
| Provider Information | |||||||||
| NPI: | 1881164440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUGER | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATTILIO | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 640 KOLTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243577234 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 879 HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243577000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2018 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | SP019521 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | SP019521 | 01 | PA | NP LICENSE | OTHER | RN635653 | 01 | PA | RN LICENSE | OTHER |