Provider Demographics
NPI:1306096532
Name:RIVECCA, NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RIVECCA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 E RYAN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4533
Mailing Address - Country:US
Mailing Address - Phone:414-768-0940
Mailing Address - Fax:
Practice Address - Street 1:200 E RYAN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-4533
Practice Address - Country:US
Practice Address - Phone:414-768-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2337023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical