Healthcare Provider Details

I. General information

NPI: 1790874485
Provider Name (Legal Business Name): PAUL CARLISLE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/18/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N496 MILKY WAY
APPLETON WI
54915-3993
US

IV. Provider business mailing address

5 HILLDALE DR
SAN ANSELMO CA
94960-2317
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT15047
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15281-24
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: