MEDICARE: NICOLE DUBISH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	085.012122	IL

General Provider Information

NPI Number	:	1275351462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE DUBISH PA

Provider Business Mailing Address
First Line	:	8897 WINDING TRL
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8778
Country	:	US
Telephone Number	:	219-789-6150
Fax Number	:

Provider Business Practice Location Address
First Line	:	9555 76TH ST
Second Line	:
City	:	PLEASANT PRAIRIE
State	:	WI
Zip	:	53158-1984
Country	:	US
Telephone Number	:	262-577-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2024
Last Update Date	:	04/20/2026

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Directions to “ NICOLE DUBISH PA” Practice Location

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