Provider Demographics
NPI:1164484747
Name:NICKELS, REBECCA A (PA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:A
Last Name:NICKELS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:KAMPERSCHROER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 26428
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-0428
Mailing Address - Country:US
Mailing Address - Phone:414-858-2200
Mailing Address - Fax:414-858-2230
Practice Address - Street 1:3237 S 16TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4526
Practice Address - Country:US
Practice Address - Phone:414-647-5165
Practice Address - Fax:414-858-2230
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1602-023363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18195Medicaid
CAWPA18195AMedicare PIN
WI003101710Medicare PIN
WIQ13837Medicare UPIN
CAWPA18195BMedicare PIN