Provider Demographics
NPI:1730500760
Name:PTAK, PAUL DANIEL (SA-C, RSA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DANIEL
Last Name:PTAK
Suffix:
Gender:M
Credentials:SA-C, RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 CHERRY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-7007
Mailing Address - Country:US
Mailing Address - Phone:847-494-1940
Mailing Address - Fax:
Practice Address - Street 1:5300 CHERRY CREEK RD
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-7007
Practice Address - Country:US
Practice Address - Phone:847-494-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant