1992937932 NPI number — MS. LORI J PACZKOWSKI COTA

Table of content: MS. LORI J PACZKOWSKI COTA (NPI 1992937932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992937932 NPI number — MS. LORI J PACZKOWSKI COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PACZKOWSKI
Provider First Name:
LORI
Provider Middle Name:
J
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992937932
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 DOUGLAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTELLO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53949-9322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-369-0004
Provider Business Mailing Address Fax Number:
920-622-3752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 SUMMIT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILD ROSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54984-6804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-622-3750
Provider Business Practice Location Address Fax Number:
920-622-3752
Provider Enumeration Date:
08/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  4679-27 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1992937932 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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