Provider Demographics
NPI:1700869526
Name:NICHOLAS, SHAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAY
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3500
Practice Address - Fax:920-433-7932
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47159-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34554700Medicaid
WI34554700Medicaid
WI0004Medicare ID - Type Unspecified