Healthcare Provider Details

I. General information

NPI: 1922311364
Provider Name (Legal Business Name): NICOLE MARIE GROSSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E 2ND ST
RICHLAND CENTER WI
53581-1900
US

IV. Provider business mailing address

301 E 2ND ST
RICHLAND CENTER WI
53581-1900
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-6161
  • Fax: 608-647-3178
Mailing address:
  • Phone: 608-647-6161
  • Fax: 608-647-3178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2607-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: