Provider Demographics
NPI:1215362462
Name:PROTIVA, JOHN M (INSURANCE AGENT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:PROTIVA
Suffix:
Gender:M
Credentials:INSURANCE AGENT
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:PTOTIVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:INSURANCE AGENT
Mailing Address - Street 1:1920 WESTMOOR TER
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1063
Mailing Address - Country:US
Mailing Address - Phone:262-827-0600
Mailing Address - Fax:262-827-0999
Practice Address - Street 1:1920 WESTMOOR TER
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-1063
Practice Address - Country:US
Practice Address - Phone:262-827-0600
Practice Address - Fax:262-827-0999
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16857171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor