Healthcare Provider Details

I. General information

NPI: 1720765191
Provider Name (Legal Business Name): NI THI MI CAO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AMERICAN AVE
WAUKESHA WI
53188-5031
US

IV. Provider business mailing address

2328 N 73RD ST
WAUWATOSA WI
53213-1210
US

V. Phone/Fax

Practice location:
  • Phone: 262-617-5663
  • Fax:
Mailing address:
  • Phone: 262-617-5663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number844923
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: