Provider Demographics
NPI:1750328563
Name:NOVAK, EDWIN A (PAC)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:A
Last Name:NOVAK
Suffix:
Gender:M
Credentials:PAC
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 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2874
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1440
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2874
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8935363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121640OtherUCARE #
MN1750328563Medicaid
MN73A13NOOtherMNBS #
MNDA9041015688OtherPREFERRED ONE #
MN0121199OtherMEDICA #
MN73A11NOOtherMNBS #
MN18231OtherNDBS #
MNHP25821OtherHEALTHPARTNERS #
MN0111296OtherMEDICA #
MN0111297OtherMEDICA #
MN022387500Medicaid
MN975261OtherAMERICA'S PPO/ARAZ #
MN0111296OtherMEDICA #
MN1750328563Medicaid
MN73A11NOOtherMNBS #
MN970001345Medicare ID - Type UnspecifiedMN MEDICARE #
MN970001346Medicare ID - Type UnspecifiedMN MEDICARE #
MN970001344Medicare ID - Type UnspecifiedMN MEDICARE #