Provider Demographics
NPI:1437492675
Name:GLADCHENKO, NICOLE M (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:GLADCHENKO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:EVERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 734240
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-4240
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:630-495-1770
Practice Address - Street 1:2500 W HIGGINS RD STE 1040
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-2049
Practice Address - Country:US
Practice Address - Phone:847-884-8096
Practice Address - Fax:847-490-0978
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3101-23363A00000X
IL085.007852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437492675OtherBCBSWI
IL1437492675Medicaid
WI1437492675Medicaid
WI2630OtherMERCYCARE INSURANCE
WIK400452296OtherWI MEDICICARE