Healthcare Provider Details

I. General information

NPI: 1497102651
Provider Name (Legal Business Name): NICHOLAS WILCOX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N15W28300 GOLF RD
PEWAUKEE WI
53072-4800
US

IV. Provider business mailing address

N15W28300 GOLF RD
PEWAUKEE WI
53072-4800
US

V. Phone/Fax

Practice location:
  • Phone: 262-303-5055
  • Fax: 262-303-5057
Mailing address:
  • Phone: 262-303-5055
  • Fax: 262-303-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD61301301
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number69772
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: