Basic Information
| Provider Information | |||||||||
| NPI: | 1437492675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLADCHENKO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVERT | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 W HIGGINS RD | ||||||||
| Address2: | STE 1040 | ||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601692049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157448554 | ||||||||
| FaxNumber: | 6304951770 | ||||||||
| Practice Location | |||||||||
| Address1: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622450535 | ||||||||
| FaxNumber: | 2622452248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2013 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3101-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | K400452296 | 01 | WI | WI MEDICICARE | OTHER | 1437492675 | 01 | WI | BCBSWI | OTHER | 2630 | 01 | WI | MERCYCARE INSURANCE | OTHER | 1437492675 | 05 | WI | MEDICAID |