Provider Demographics
NPI:1790188498
Name:GERHARTZ, NICOLAI
Entity Type:Individual
Prefix:
First Name:NICOLAI
Middle Name:
Last Name:GERHARTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 UNIVERSITY AVE
Mailing Address - Street 2:APT 96
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53726-3863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W832 COUNTY RD S
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-1116
Practice Address - Country:US
Practice Address - Phone:262-384-0772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3633250376K00000X
WI4605-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No376K00000XNursing Service Related ProvidersNurse's Aide