Provider Demographics
NPI:1639488406
Name:NILES, ROBERT J (PAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:NILES
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 GRIFFIN ST. EAST
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1439
Mailing Address - Country:US
Mailing Address - Phone:715-268-8000
Mailing Address - Fax:715-268-0311
Practice Address - Street 1:265 GRIFFIN ST. EAST
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1439
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:715-268-0311
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2713-23363A00000X
MN10827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639488406Medicaid
MN1639488406Medicaid
MN1639488406Medicaid
WI004960134Medicare Oscar/Certification