Provider Demographics
NPI:1851613467
Name:COULTER, BLAKE T (NP)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:T
Last Name:COULTER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 NW 52ND TERRACE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151
Mailing Address - Country:US
Mailing Address - Phone:816-830-5042
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:MS1020
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-3807
Practice Address - Fax:913-588-3877
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS75958363L00000X
MO2005007561363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00976936OtherRAILROAD MEDICARE PTAN
MOP00976936OtherRAILROAD MEDICARE PTAN