Healthcare Provider Details

I. General information

NPI: 1124933007
Provider Name (Legal Business Name): NICHOLAS BACON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 SPUR RD APT 215
MEQUON WI
53092-4430
US

IV. Provider business mailing address

6250 SPUR RD APT 215
MEQUON WI
53092-4430
US

V. Phone/Fax

Practice location:
  • Phone: 262-909-0561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number26589530
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: