Provider Demographics
NPI:1093404279
Name:PRATER, DEVIN DESHON (PTA)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:DESHON
Last Name:PRATER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:DEVIN
Other - Middle Name:DESHON
Other - Last Name:PRATER-DUDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7110 LACKMAN RD APT 808
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66217-8330
Mailing Address - Country:US
Mailing Address - Phone:816-752-0328
Mailing Address - Fax:
Practice Address - Street 1:12000 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2705
Practice Address - Country:US
Practice Address - Phone:913-735-0997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-04091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant