Provider Demographics
NPI:1346379625
Name:PRATT FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:PRATT FAMILY PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WAKON
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-672-7422
Mailing Address - Street 1:203 WATSON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-3066
Mailing Address - Country:US
Mailing Address - Phone:620-672-7422
Mailing Address - Fax:620-450-1601
Practice Address - Street 1:203 WATSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-3066
Practice Address - Country:US
Practice Address - Phone:620-672-7422
Practice Address - Fax:620-450-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS178987261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS178987Medicare ID - Type UnspecifiedRURAL HEALTH