Provider Demographics
NPI:1154346518
Name:NIGBOR, TOMMY D (PA-C)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:D
Last Name:NIGBOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15954 RIVERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7800
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:715-634-5740
Practice Address - Street 1:15954 RIVERS EDGE DR
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-7800
Practice Address - Country:US
Practice Address - Phone:715-634-2541
Practice Address - Fax:715-634-5740
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI708363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42938700Medicaid
WI42938700Medicaid
WI66005-0011Medicare ID - Type UnspecifiedMEDICARE