Provider Demographics
NPI:1194719195
Name:PUTT, PAUL DENNIS (AT, C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DENNIS
Last Name:PUTT
Suffix:
Gender:M
Credentials:AT, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 E REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7204
Mailing Address - Country:US
Mailing Address - Phone:417-889-4411
Mailing Address - Fax:
Practice Address - Street 1:1317 E REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7204
Practice Address - Country:US
Practice Address - Phone:417-889-4411
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1099362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer