MEDICARE: NICOLE MARIE JODAT 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	2335-023	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871742627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE JODAT PA-C

Provider Business Mailing Address
First Line	:	601 N BARKER RD STE 110
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-5929
Country	:	US
Telephone Number	:	262-785-0777
Fax Number	:	262-785-8029

Provider Business Practice Location Address
First Line	:	601 N BARKER RD STE 110
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-5929
Country	:	US
Telephone Number	:	262-785-0777
Fax Number	:	262-785-8029

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

Provider Enumeration Date	:	09/17/2008
Last Update Date	:	04/03/2020

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