Provider Demographics
NPI:1225805609
Name:NOVAK, DANIELLE R
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:R
Last Name:NOVAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 TRISTRAM LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1488
Mailing Address - Country:US
Mailing Address - Phone:814-505-3503
Mailing Address - Fax:
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2965
Practice Address - Country:US
Practice Address - Phone:704-446-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14038363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical