Provider Demographics
NPI:1508956855
Name:WAMBOLD, PAUL ANTHONY (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:WAMBOLD
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 1:4602 EASTPARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-2002
Mailing Address - Country:US
Mailing Address - Phone:608-440-6440
Mailing Address - Fax:
Practice Address - Street 1:4602 EASTPARK BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2002
Practice Address - Country:US
Practice Address - Phone:608-440-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7368225100000X
IL070020702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist