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Individual
MR. BLAKE T COULTER
Active
Individual
MR. BLAKE T COULTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
N.P.
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
75958
KS
363LF0000X
Family Nurse Practitioner
2005007561
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00976936
RAILROAD MEDICARE PTAN
MO
Enumeration date
02/23/2010
Last updated
07/19/2017
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