Provider Demographics
NPI:1780608760
Name:NOVAK, KEN D (PA)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:D
Last Name:NOVAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W. ELDORADO PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068
Mailing Address - Country:US
Mailing Address - Phone:972-292-0300
Mailing Address - Fax:
Practice Address - Street 1:800 W. ELDORADO PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068
Practice Address - Country:US
Practice Address - Phone:972-292-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182410403Medicaid
TX182410401Medicaid
TX182410404Medicaid
TX182410405Medicaid
TX182410402Medicaid
TX182410406Medicaid
TX182410405Medicaid
TX182410404Medicaid
TX8L9589Medicare PIN
TX8D0019Medicare ID - Type Unspecified
TX8L10157Medicare PIN
TX8J6717Medicare PIN
TX8L10158Medicare PIN