Healthcare Provider Details

I. General information

NPI: 1427760057
Provider Name (Legal Business Name): NICHOLAS ALEXANDER KUTRUBS C-AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

339 CONSORT DR
BALLWIN MO
63011-4439
US

V. Phone/Fax

Practice location:
  • Phone: 636-386-9224
  • Fax: 636-386-7679
Mailing address:
  • Phone: 636-386-9224
  • Fax: 636-386-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2023003008
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberPENDING
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: