Healthcare Provider Details

I. General information

NPI: 1821779067
Provider Name (Legal Business Name): CARLOS A NIEVES III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2461 HOLMGREN WAY
GREEN BAY WI
54304-5224
US

IV. Provider business mailing address

2461 HOLMGREN WAY
GREEN BAY WI
54304-5224
US

V. Phone/Fax

Practice location:
  • Phone: 920-272-3326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: