Provider Demographics
NPI:1093822447
Name:NIEC, KENNETH M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:NIEC
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:248 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105
Practice Address - Country:US
Practice Address - Phone:262-767-8110
Practice Address - Fax:262-767-8212
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI1215-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41924900Medicaid
MN0615267OtherDEA NUMBER
WI41924900Medicaid