Basic Information
| Provider Information | |||||||||
| NPI: | 1508845827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GINTNER | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 PINE ST | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547681297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156445530 | ||||||||
| FaxNumber: | 7156446223 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 S CLARK ST | ||||||||
| Address2: | |||||||||
| City: | THORP | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547717624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156697279 | ||||||||
| FaxNumber: | 7156695674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 12/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 486 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42922800 | 05 | WI | MEDICAID |