Healthcare Provider Details

I. General information

NPI: 1902006521
Provider Name (Legal Business Name): GREGORY A. POULTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2007
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE DIVISION OF NEPHROLOGY
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE DIVISION OF NEPHROLOGY
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3100
  • Fax: 414-259-1145
Mailing address:
  • Phone: 414-805-3100
  • Fax: 414-259-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2159
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: