Provider Demographics
NPI:1942519418
Name:LAABS, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LAABS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2555 N MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-267-2080
Mailing Address - Fax:414-267-8570
Practice Address - Street 1:2555 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-267-2080
Practice Address - Fax:414-267-8570
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2677-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400308317OtherMEDICARE PTAN