Provider Demographics
NPI:1700474772
Name:KOWALSKI, NICOLE MARION (CAA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARION
Last Name:KOWALSKI
Suffix:
Gender:F
Credentials:CAA
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:14900 LIBRARY LN UNIT 326
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-3560
Practice Address - Fax:414-266-6092
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2024-03-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI176367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700474772Medicaid