Provider Demographics
NPI:1730132010
Name:NOVAK, VICKI LYNN (PA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:NOVAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:L
Other - Last Name:WINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:110 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1022
Practice Address - Country:US
Practice Address - Phone:563-422-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3385363AM0700X
IA2211363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ021430001Medicaid
AZQ65029Medicare UPIN
AZQ65029Medicare UPIN