Provider Demographics
NPI:1871742627
Name:JODAT, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:JODAT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:SELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:601 N BARKER RD STE 110
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5929
Mailing Address - Country:US
Mailing Address - Phone:262-785-0777
Mailing Address - Fax:262-785-8029
Practice Address - Street 1:601 N BARKER RD STE 110
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5929
Practice Address - Country:US
Practice Address - Phone:262-785-0777
Practice Address - Fax:262-785-8029
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2335-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871742627Medicaid