Provider Demographics
NPI:1356380075
Name:NOVAS, NISSA M
Entity type:Individual
Prefix:DR
First Name:NISSA
Middle Name:M
Last Name:NOVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 CHILEAN TEAL TER
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-7141
Mailing Address - Country:US
Mailing Address - Phone:301-430-7317
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4017
Practice Address - Country:US
Practice Address - Phone:301-855-1012
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061635207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDI14700Medicare UPIN
MD584L-J350Medicare ID - Type Unspecified