Provider Demographics
NPI:1619054442
Name:KOLTNOW, PAUL J (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:KOLTNOW
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:P.O. BOX 742392
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2392
Mailing Address - Country:US
Mailing Address - Phone:901-227-4068
Mailing Address - Fax:901-227-4051
Practice Address - Street 1:80 HUMPHREYS CENTER
Practice Address - Street 2:SUITE 200
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-578-2538
Practice Address - Fax:901-578-2572
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-03-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN1087363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ05246Medicare UPIN