Provider Demographics
NPI:1659957058
Name:PAULETICH, MARK WAYNNE (RRT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNNE
Last Name:PAULETICH
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9402 PRESERVE TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-7501
Mailing Address - Country:US
Mailing Address - Phone:715-529-6210
Mailing Address - Fax:
Practice Address - Street 1:N7, N12 & FORT DEFIANCE
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36452279C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2279C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredCritical CareGroup - Single Specialty