Provider Demographics
NPI:1801382494
Name:NOWAK, MICHAEL BASTIEN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BASTIEN
Last Name:NOWAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:NOWAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN (NURSE PRACT)
Mailing Address - Street 1:204 W 4TH ST APT 13
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-2835
Mailing Address - Country:US
Mailing Address - Phone:360-733-6114
Mailing Address - Fax:
Practice Address - Street 1:751 LOMBARDI CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-6798
Practice Address - Country:US
Practice Address - Phone:360-733-6114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60149798163W00000X
CA95164925163W00000X
WAAP60864126363LF0000X
CA95009174363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95164925OtherCA RN LISCENSE
WAAP60864126OtherWA APRN LICENSE NUMBER
WARN60149798OtherWA RN LISCENSE
CA95009174OtherCA APRN LICENSE NUMBER
CA95009174OtherCA NURSE PRACTITIONER FURNISHING NUMBER