Provider Demographics
NPI:1760112387
Name:UTSLER, PAUL JACK
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JACK
Last Name:UTSLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COMMODORE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-2101
Mailing Address - Country:US
Mailing Address - Phone:331-214-2559
Mailing Address - Fax:
Practice Address - Street 1:5 COMMODORE DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-2101
Practice Address - Country:US
Practice Address - Phone:331-214-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
3927OtherNEMT