Provider Demographics
NPI:1508845827
Name:GINTNER, PETER P (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:GINTNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 PINE ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-1297
Mailing Address - Country:US
Mailing Address - Phone:715-644-5530
Mailing Address - Fax:715-644-6223
Practice Address - Street 1:704 S CLARK ST
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771-7624
Practice Address - Country:US
Practice Address - Phone:715-669-7279
Practice Address - Fax:715-669-5674
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42922800Medicaid
14040-0002Medicare PIN
R97689Medicare UPIN