Provider Demographics
NPI:1871579961
Name:WISNIEWSKI, NICOLLE KAHL (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:KAHL
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:NICOLLE
Other - Middle Name:KAHL
Other - Last Name:HENDRIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:3801 LAKE OTIS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5234
Mailing Address - Country:US
Mailing Address - Phone:907-562-2277
Mailing Address - Fax:907-563-3460
Practice Address - Street 1:3801 LAKE OTIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5234
Practice Address - Country:US
Practice Address - Phone:907-562-2277
Practice Address - Fax:907-563-3460
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1000363AM0700X, 363AS0400X
MN9868363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1575427Medicaid
MN991491900Medicaid
AK1575427Medicaid
AKMH2453924OtherDEA
MN970001859Medicare ID - Type Unspecified
Q05178Medicare UPIN
MN991491900Medicaid