Provider Demographics
NPI:1396264917
Name:PAESL, BROCK A
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:A
Last Name:PAESL
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:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-0355
Mailing Address - Country:US
Mailing Address - Phone:402-494-3337
Mailing Address - Fax:402-494-3356
Practice Address - Street 1:1201 ARBOR DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-2652
Practice Address - Country:US
Practice Address - Phone:402-494-3337
Practice Address - Fax:402-494-3356
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE175T00000X, 175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist