Provider Demographics
NPI:1639715543
Name:WINCHESTER, PAUL ERIC (PTA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ERIC
Last Name:WINCHESTER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3962
Practice Address - Country:US
Practice Address - Phone:618-453-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant