Provider Demographics
NPI:1902006521
Name:POULTON, GREGORY A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:A
Last Name:POULTON
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF NEPHROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3100
Mailing Address - Fax:414-259-1145
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF NEPHROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3100
Practice Address - Fax:414-259-1145
Is Sole Proprietor?:No
Enumeration Date:2007-07-22
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902006521Medicaid
WI036V73601Medicare PIN