Provider Demographics
NPI:1255412185
Name:OMICK, NATHAN JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:JAMES
Last Name:OMICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-0221
Mailing Address - Country:US
Mailing Address - Phone:262-567-4497
Mailing Address - Fax:262-567-3716
Practice Address - Street 1:N58W39799 W HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066
Practice Address - Country:US
Practice Address - Phone:262-567-4497
Practice Address - Fax:262-567-3716
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38967300Medicaid
WI000346046Medicare ID - Type Unspecified
WI38967300Medicaid