Healthcare Provider Details

I. General information

NPI: 1669837381
Provider Name (Legal Business Name): NICHOLAS SUYDAM MS, PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 FISH HATCHERY RD
MADISON WI
53715-1909
US

IV. Provider business mailing address

1211 FISH HATCHERY RD
MADISON WI
53715-1909
US

V. Phone/Fax

Practice location:
  • Phone: 608-252-8000
  • Fax: 608-288-6490
Mailing address:
  • Phone: 608-252-8000
  • Fax: 608-288-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7885-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: