Provider Demographics
NPI:1124564000
Name:NOVAK, ANDREW (PA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
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 1:1920 N HIGLEY RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-1623
Mailing Address - Country:US
Mailing Address - Phone:480-543-6600
Mailing Address - Fax:
Practice Address - Street 1:1920 N HIGLEY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1623
Practice Address - Country:US
Practice Address - Phone:805-436-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6442363A00000X
WI4332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1124564000Medicaid