Provider Demographics
NPI:1881863157
Name:NOVAK, WANDA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:M
Last Name:NOVAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:MOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7929 JACKPOT AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-3649
Mailing Address - Country:US
Mailing Address - Phone:608-487-9133
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2248-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical