Provider Demographics
NPI:1487676870
Name:POTOS, PAUL W (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:POTOS
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 1:1300 S GREEN BAY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4469
Mailing Address - Country:US
Mailing Address - Phone:262-898-3930
Mailing Address - Fax:262-321-0242
Practice Address - Street 1:3840 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-2239
Practice Address - Country:US
Practice Address - Phone:414-962-8480
Practice Address - Fax:414-962-8476
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4570-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40347400Medicaid
WI40347400Medicaid