Provider Demographics
NPI:1720416431
Name:NOVIKOFF, MEGAN THERESA (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:THERESA
Last Name:NOVIKOFF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:T
Other - Last Name:LUCIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS STREET
Mailing Address - Street 2:HIDALGO MEDICAL SERVICES
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-2388
Practice Address - Street 1:3200 SILVER STREET
Practice Address - Street 2:HMS SHS WELLNESS CENTER
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7283
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:575-542-2388
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR165097363A00000X
NMPA2015-0013363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60902230Medicaid
NM60902230Medicaid