Provider Demographics
NPI:1922003359
Name:PAULS, BRUCE DALE (PT,MS,ATC)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:DALE
Last Name:PAULS
Suffix:
Gender:M
Credentials:PT,MS,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 W PLATT ST
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-2118
Mailing Address - Country:US
Mailing Address - Phone:563-652-4364
Mailing Address - Fax:563-652-6818
Practice Address - Street 1:616 W PLATT ST
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2118
Practice Address - Country:US
Practice Address - Phone:563-652-4364
Practice Address - Fax:563-652-6818
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0769225100000X
IA000822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0199000Medicaid
IA0199000Medicaid