Provider Demographics
NPI:1093781452
Name:NICKELE, GLENN A (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:NICKELE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ST. CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3261
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:216 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9449
Practice Address - Country:US
Practice Address - Phone:715-483-3221
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42548207RC0000X
WI32220207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN468980100Medicaid
060001548Medicare ID - Type Unspecified
MN468980100Medicaid