Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 37383 | WI |
NPI | 1003830142 |
---|---|
Provider Name | William Nicholson |
First Address | Racine, WI 53405-1667 |
Second Address | West Allis, WI 53227-2142 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2006 |
Last Update Date | 13/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F84254 | (02) | WI |