Provider Demographics
NPI:1720328271
Name:PADDACK, MICHAEL EDWARD (ATC, PTA, CPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:PADDACK
Suffix:
Gender:M
Credentials:ATC, PTA, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 ROCKFELLOW DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9404
Mailing Address - Country:US
Mailing Address - Phone:530-926-2599
Mailing Address - Fax:
Practice Address - Street 1:1011 ROCKFELLOW DR
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-9404
Practice Address - Country:US
Practice Address - Phone:530-926-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT4271225200000X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer