Provider Demographics
NPI:1386674547
Name:NOWAK, DEBORAH M (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:M
Last Name:NOWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:M
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11407 CREEKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4311
Mailing Address - Country:US
Mailing Address - Phone:952-836-8513
Mailing Address - Fax:
Practice Address - Street 1:6565 FRANCE AVE S STE 350
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:612-389-1093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48182208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN096028400Medicaid
MN096028400Medicaid
MN020002207Medicare ID - Type UnspecifiedMEDICARE