Provider Demographics
NPI:1275598781
Name:NOWAK, KRISTIE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:NOWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6799 GREAT OAKS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2584
Mailing Address - Country:US
Mailing Address - Phone:901-685-3490
Mailing Address - Fax:901-685-3499
Practice Address - Street 1:6029 WALNUT GROVE RD STE C002
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-685-3490
Practice Address - Fax:901-685-3499
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036153201207RI0200X
TN56938207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVH23270Medicare UPIN
4181861Medicare PIN