Basic Information
Provider Information | |||||||||
NPI: | 1871579961 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WISNIEWSKI | ||||||||
FirstName: | NICOLLE | ||||||||
MiddleName: | KAHL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPAS, PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HENDRIX | ||||||||
OtherFirstName: | NICOLLE | ||||||||
OtherMiddleName: | KAHL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MPAS, PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1919 LATHROP ST | ||||||||
Address2: | STE # 105 | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997015937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074516561 | ||||||||
FaxNumber: | 9074528912 | ||||||||
Practice Location | |||||||||
Address1: | 1001 NOBLE ST | ||||||||
Address2: |   | ||||||||
City: | FAIRBANKS | ||||||||
State: | AK | ||||||||
PostalCode: | 997014922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074593500 | ||||||||
FaxNumber: | 9074582653 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2005 | ||||||||
LastUpdateDate: | 12/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1000 | AK | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 9868 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 1000 | AK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 991491900 | 05 | MN |   | MEDICAID | MH2453924 | 01 | AK | DEA | OTHER | 1575427 | 05 | AK |   | MEDICAID |