Provider Demographics
NPI:1467415273
Name:SCHWENSOW, NICOLE M (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SCHWENSOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:CIRCLE
Mailing Address - State:MT
Mailing Address - Zip Code:59215-7514
Mailing Address - Country:US
Mailing Address - Phone:406-485-2063
Mailing Address - Fax:
Practice Address - Street 1:605 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:CIRCLE
Practice Address - State:MT
Practice Address - Zip Code:59215-7514
Practice Address - Country:US
Practice Address - Phone:406-485-2063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1753-23363A00000X
WI1753-023363AS0400X
CO4056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98476343Medicaid
CO027170OtherKAISER COMMERCIAL NUMBER
WI41992700Medicaid
WI1467415273Medicaid
WI41992700Medicaid
WI686550162Medicare PIN
CO98476343Medicaid
CO502948YK5YMedicare PIN
WI014000144Medicare PIN
WI001246330Medicare PIN