=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366892101
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. PAUL DAENTL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2016
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1704 MENOMONIE ST APT 2
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-484-9718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 MENOMONIE ST APT 2
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-484-9718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1938
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A901
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------