Provider Demographics
NPI:1679595433
Name:NOWAK, JOHN (PAC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:NOWAK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:489 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-947-6336
Mailing Address - Fax:207-947-6537
Practice Address - Street 1:489 STATE STREET
Practice Address - Street 2:EASTERN MAINE MEDICAL CENTER
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-947-6336
Practice Address - Fax:207-947-6537
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA870363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q45400Medicare UPIN