Healthcare Provider Details

I. General information

NPI: 1649792235
Provider Name (Legal Business Name): NICHOLAS KRIESEL PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N15W28300 GOLF RD
PEWAUKEE WI
53072-4800
US

IV. Provider business mailing address

10610 W ROGERS ST
WEST ALLIS WI
53227-1247
US

V. Phone/Fax

Practice location:
  • Phone: 262-303-5055
  • Fax:
Mailing address:
  • Phone: 414-530-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4910
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: