Basic Information
| Provider Information | |||||||||
| NPI: | 1801061551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SINCLAIR | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHYISCIAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 617 S ROOSEVELT ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457217 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 S ROOSEVELT ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457217 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 629024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40136500 | 05 | WI | MEDICAID |