Healthcare Provider Details

I. General information

NPI: 1992166821
Provider Name (Legal Business Name): NICHOLAS W HAWLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2016
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 W GOOD HOPE RD # BCM320
MILWAUKEE WI
53209-2042
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-352-3100
  • Fax:
Mailing address:
  • Phone: 414-389-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number71430
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: