Provider Demographics
NPI:1407940497
Name:NOWACK, MICHAEL VICTOR (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VICTOR
Last Name:NOWACK
Suffix:
Gender:M
Credentials:DPT
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 3482
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877-3482
Mailing Address - Country:US
Mailing Address - Phone:208-209-6170
Mailing Address - Fax:208-209-6169
Practice Address - Street 1:6186 W MAINE
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:ID
Practice Address - Zip Code:83869
Practice Address - Country:US
Practice Address - Phone:208-623-6717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8446924Medicaid
WA0201431OtherLABOR AND INDUSTRIES
WA0201431OtherLABOR AND INDUSTRIES
WAP50811Medicare ID - Type Unspecified