Provider Demographics
NPI:1326018904
Name:NICHOLSON, JEFFREY GERARD (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:GERARD
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7033 WELLAUER DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3734
Mailing Address - Country:US
Mailing Address - Phone:414-517-6915
Mailing Address - Fax:414-877-1700
Practice Address - Street 1:19035 W CAPITOL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2755
Practice Address - Country:US
Practice Address - Phone:262-754-1421
Practice Address - Fax:262-754-3760
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI904-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42981400Medicaid
WIWI1826001OtherMEDCARE PTAN
WIWI1826001OtherMEDCARE PTAN
WI003502905Medicare PIN
WI005401473Medicare PIN
WI003502905Medicare PIN