MEDICARE: NICOLE RIVECCA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	2337023	WI

General Provider Information

NPI Number	:	1306096532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE RIVECCA PA-C

Provider Business Mailing Address
First Line	:	200 E RYAN RD
Second Line	:	SUITE 101
City	:	OAK CREEK
State	:	WI
Zip	:	53154-4533
Country	:	US
Telephone Number	:	414-768-0940
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 E RYAN RD
Second Line	:	SUITE 101
City	:	OAK CREEK
State	:	WI
Zip	:	53154-4533
Country	:	US
Telephone Number	:	414-768-0940
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	11/17/2008

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