Provider Demographics
NPI:1851806764
Name:PAWLIK, GREGORY JOSEPH
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOSEPH
Last Name:PAWLIK
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 1:415 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4514
Mailing Address - Country:US
Mailing Address - Phone:701-446-1014
Mailing Address - Fax:701-446-1200
Practice Address - Street 1:415 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4514
Practice Address - Country:US
Practice Address - Phone:701-446-1014
Practice Address - Fax:701-446-1200
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2242ZOOOOOXMedicaid