Provider Demographics
NPI:1174511703
Name:SJAK-SHIE, NELIDA N (PHD MD)
Entity Type:Individual
Prefix:
First Name:NELIDA
Middle Name:N
Last Name:SJAK-SHIE
Suffix:
Gender:F
Credentials:PHD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6348 CTY RD JJ
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:SUITE W120
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-735-7300
Practice Address - Fax:920-735-7333
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001031729207RH0003X
WI63276207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205706625Medicaid
MO830008126Medicare PIN
MO205706625Medicaid
MO004013483Medicare PIN
MOP00104180Medicare PIN
H30937Medicare UPIN