Basic Information
| Provider Information | |||||||||
| NPI: | 1568787794 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ANTOS | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC PULMONARY MEDICINE | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142666730 | ||||||||
| FaxNumber: | 4142666742 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC PULMONARY MEDICINE | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142666730 | ||||||||
| FaxNumber: | 4142666742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 54265 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0214X | 54265 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 1568787794 | 05 | WI | MEDICAID |