Provider Demographics
NPI:1114929023
Name:NOWAK, DAVID J (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:NOWAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 MEADOW TRL W
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-5327
Mailing Address - Country:US
Mailing Address - Phone:815-758-3636
Mailing Address - Fax:
Practice Address - Street 1:3319 MEADOW TRL W
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-5327
Practice Address - Country:US
Practice Address - Phone:815-758-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-04039207LP2900X
IL207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK13338Medicare PIN
ILP85383Medicare UPIN