Provider Demographics
NPI:1255694790
Name:HALLETT, NICHOLAS A (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:HALLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 S STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2257
Mailing Address - Country:US
Mailing Address - Phone:608-260-6000
Mailing Address - Fax:
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6289
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67420-20208000000X
IN01075425A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255694790Medicaid