Provider Demographics
NPI:1225187768
Name:PASCHALL, PAUL WAYNE (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:WAYNE
Last Name:PASCHALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 MACON AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3403
Mailing Address - Country:US
Mailing Address - Phone:719-269-1142
Mailing Address - Fax:719-269-1413
Practice Address - Street 1:903 MACON AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3403
Practice Address - Country:US
Practice Address - Phone:719-269-1142
Practice Address - Fax:719-269-1413
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76529843Medicaid
COC479958OtherMEDICARE ID-PIN
COC479958OtherMEDICARE ID-PIN