Healthcare Provider Details

I. General information

NPI: 1326018904
Provider Name (Legal Business Name): JEFFREY GERARD NICHOLSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 08/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19035 W CAPITOL DR SUITE 101
BROOKFIELD WI
53045-2755
US

IV. Provider business mailing address

7033 WELLAUER DR
MILWAUKEE WI
53213-3734
US

V. Phone/Fax

Practice location:
  • Phone: 262-754-1421
  • Fax: 262-754-3760
Mailing address:
  • Phone: 414-517-6915
  • Fax: 414-877-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number904-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: