Provider Demographics
NPI:1053866541
Name:PRUTER, DAXTEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DAXTEN
Middle Name:
Last Name:PRUTER
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 E LINWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64128-2226
Mailing Address - Country:US
Mailing Address - Phone:816-446-4082
Mailing Address - Fax:
Practice Address - Street 1:4251 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64133-1593
Practice Address - Country:US
Practice Address - Phone:181-686-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0121556163W00000X
KS53-79163-032363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse