Provider Demographics
NPI:1750701736
Name:NEAL-NOVAK, ELISABETH G (PA-C)
Entity type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:G
Last Name:NEAL-NOVAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:G
Other - Last Name:NOVAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2330 MARINSHIP WAY STE 370
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-2853
Mailing Address - Country:US
Mailing Address - Phone:415-887-9758
Mailing Address - Fax:
Practice Address - Street 1:2330 MARINSHIP WAY STE 370
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965
Practice Address - Country:US
Practice Address - Phone:415-887-9758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56731363A00000X, 207N00000X
NH1017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1017OtherSTATE LICENSE