Provider Demographics
NPI:1811991359
Name:NOWAK, MICHAEL J (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:NOWAK
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 1:1932 ALCOA HWY
Mailing Address - Street 2:STE 270
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1537
Mailing Address - Country:US
Mailing Address - Phone:865-251-4658
Mailing Address - Fax:865-251-4659
Practice Address - Street 1:1932 ALCOA HWY STE 270
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1537
Practice Address - Country:US
Practice Address - Phone:865-251-4658
Practice Address - Fax:865-251-4659
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10410363A00000X
WI1692363AS0400X
TN3305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
WI41984300Medicaid
MN970003456Medicare PIN
WI41984300Medicaid
MN970005275Medicare PIN
P96573Medicare UPIN