Provider Demographics
NPI:1922023019
Name:RUTTER, KIM M (PA-C, RPH)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:RUTTER
Suffix:
Gender:F
Credentials:PA-C, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 N 105TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3327
Mailing Address - Country:US
Mailing Address - Phone:414-453-5235
Mailing Address - Fax:
Practice Address - Street 1:3111 W RAWSON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9417
Practice Address - Country:US
Practice Address - Phone:414-325-4370
Practice Address - Fax:414-761-0713
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11878183500000X
WI1842-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant