Provider Demographics
NPI:1265122022
Name:HONOR ON-SITE CLINIC
Entity type:Organization
Organization Name:HONOR ON-SITE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FICK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:715-558-3510
Mailing Address - Street 1:W179S6914 MUSKEGO DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-9631
Mailing Address - Country:US
Mailing Address - Phone:715-558-3510
Mailing Address - Fax:
Practice Address - Street 1:W183S8750 RACINE AVE # 3
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-8067
Practice Address - Country:US
Practice Address - Phone:262-971-1798
Practice Address - Fax:262-679-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42946900Medicaid
1932182177OtherBCBS WISCONSIN