Provider Demographics
NPI:1336786078
Name:NICOSKI, JEREMY MICHAEL
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:NICOSKI
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 1:1922 WHIPPOORWILL WAY
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4706
Mailing Address - Country:US
Mailing Address - Phone:320-493-1477
Mailing Address - Fax:
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1452
Practice Address - Country:US
Practice Address - Phone:906-483-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704334699367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered