Provider Demographics
NPI:1265731590
Name:THEUERKAUF, PAUL MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:THEUERKAUF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 SHADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48632-9154
Mailing Address - Country:US
Mailing Address - Phone:616-862-9714
Mailing Address - Fax:
Practice Address - Street 1:309 N BARTLETT ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2127
Practice Address - Country:US
Practice Address - Phone:616-862-9714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11668-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist