Healthcare Provider Details

I. General information

NPI: 1932029006
Provider Name (Legal Business Name): PATRICK PAUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-1000
US

IV. Provider business mailing address

11202 HESS WAY
OXFORD FL
34484-3474
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9655242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: