Provider Demographics
NPI:1043388796
Name:FOX, NICOLE M (PAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:FOX
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:JAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:8700 W WATERTOWN PLANK RD
Mailing Address - Street 2:DEPT OF ORTHOPAEDIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3595
Mailing Address - Country:US
Mailing Address - Phone:414-805-7100
Mailing Address - Fax:414-805-7171
Practice Address - Street 1:8700 W WATERTOWN PLANK RD
Practice Address - Street 2:DEPT OF ORTHOPAEDIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3595
Practice Address - Country:US
Practice Address - Phone:414-805-7100
Practice Address - Fax:414-805-7171
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00166100363A00000X
WI2347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043388796Medicaid