Provider Demographics
NPI:1962028985
Name:NOVAK, ELENA (PA)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:NOVAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30280 RANCHO VIEJO RD
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1561
Mailing Address - Country:US
Mailing Address - Phone:949-248-1632
Mailing Address - Fax:
Practice Address - Street 1:30280 RANCHO VIEJO RD
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1561
Practice Address - Country:US
Practice Address - Phone:949-248-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant