Provider Demographics
NPI:1083356406
Name:NOVACINSKI, ETHAN GRANT
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:GRANT
Last Name:NOVACINSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9558 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MN
Mailing Address - Zip Code:56374-8720
Mailing Address - Country:US
Mailing Address - Phone:320-223-9732
Mailing Address - Fax:
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN14620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program