Healthcare Provider Details

I. General information

NPI: 1164095956
Provider Name (Legal Business Name): NICHOLAS HANKE CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 PINE RIDGE BLVD
WAUSAU WI
54401-4102
US

IV. Provider business mailing address

2400 PINE RIDGE BLVD
WAUSAU WI
54401-7803
US

V. Phone/Fax

Practice location:
  • Phone: 715-847-2022
  • Fax:
Mailing address:
  • Phone: 715-847-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number179985
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: