Provider Demographics
NPI:1922035765
Name:NOWAK, JEFFREY M (NP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:NOWAK
Suffix:
Gender:M
Credentials:NP
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:7777 FOREST LN STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-566-7790
Practice Address - Fax:972-566-5819
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX658745363L00000X, 363LA2100X
TXAP112695363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171609407Medicaid
TX171609402Medicaid
TX171609403Medicaid
TX171609401Medicaid
TXQ10632Medicare UPIN
TX171609402Medicaid
TX8J6688Medicare PIN
TX171609403Medicaid