Healthcare Provider Details

I. General information

NPI: 1275351462
Provider Name (Legal Business Name): NICOLE DUBISH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 76TH ST
PLEASANT PRAIRIE WI
53158-1984
US

IV. Provider business mailing address

8897 WINDING TRL
SAINT JOHN IN
46373-8778
US

V. Phone/Fax

Practice location:
  • Phone: 262-577-8000
  • Fax:
Mailing address:
  • Phone: 219-789-6150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.012122
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: