Provider Demographics
NPI:1790715225
Name:NOVAK, MOIRA DOYLE (ATC)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:DOYLE
Last Name:NOVAK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8488 SAVANNA OAKS LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9460
Mailing Address - Country:US
Mailing Address - Phone:651-994-0127
Mailing Address - Fax:
Practice Address - Street 1:516 15TH AVE SE
Practice Address - Street 2:ROOM 190 BFAB
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0130
Practice Address - Country:US
Practice Address - Phone:612-624-5084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer