Provider Demographics
NPI:1467218305
Name:STALEY, PAUL TIMOTHY
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:TIMOTHY
Last Name:STALEY
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 1:1234 ODELL FARM LN
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-7772
Mailing Address - Country:US
Mailing Address - Phone:126-922-4769
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1640
Practice Address - Country:US
Practice Address - Phone:269-226-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist