Provider Demographics
NPI:1124564000
Name:NOVAK, ANDREW (PA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:NOVAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-3635
Mailing Address - Fax:
Practice Address - Street 1:800 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:087-850-9406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4332363A00000X
AZ6442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant