Provider Demographics
NPI:1366892101
Name:DAENTL, PAUL
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:DAENTL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 MENOMONIE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-6286
Mailing Address - Country:US
Mailing Address - Phone:952-484-9718
Mailing Address - Fax:
Practice Address - Street 1:1704 MENOMONIE ST APT 2
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-6286
Practice Address - Country:US
Practice Address - Phone:952-484-9718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1938225200000X
MNA901225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant