Provider Demographics
NPI:1811494917
Name:FISCH, NICOLE KRISTEN (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KRISTEN
Last Name:FISCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:777 PARK AVE W STE B131A
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2433
Mailing Address - Country:US
Mailing Address - Phone:847-570-2868
Mailing Address - Fax:630-733-5005
Practice Address - Street 1:777 PARK AVE W STE B131A
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2433
Practice Address - Country:US
Practice Address - Phone:847-570-2868
Practice Address - Fax:630-733-5005
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006561363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant