Provider Demographics
NPI:1063498673
Name:NIKSICH, PAMELA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:NIKSICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6307
Mailing Address - Country:US
Mailing Address - Phone:763-559-2861
Mailing Address - Fax:763-559-1338
Practice Address - Street 1:12720 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6307
Practice Address - Country:US
Practice Address - Phone:763-559-2861
Practice Address - Fax:763-559-1338
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45836208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics