Provider Demographics
NPI:1518065101
Name:NIESEN, MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NIESEN
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 1:112 HELEN ST
Mailing Address - Street 2:
Mailing Address - City:SAUK CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53583-1101
Mailing Address - Country:US
Mailing Address - Phone:608-643-3351
Mailing Address - Fax:608-643-3621
Practice Address - Street 1:112 HELEN ST
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583-1101
Practice Address - Country:US
Practice Address - Phone:608-643-3351
Practice Address - Fax:608-643-3621
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42973700Medicaid
WI42973700Medicaid