Provider Demographics
NPI:1306807292
Name:NOVAK, JOHN (PA)
Entity type:Individual
Prefix:
First Name:JOHN
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 1:3420 HARDWAY LN
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-5123
Mailing Address - Country:US
Mailing Address - Phone:440-350-1519
Mailing Address - Fax:
Practice Address - Street 1:1224 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4802
Practice Address - Country:US
Practice Address - Phone:931-359-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000610363A00000X
TN1906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S95124Medicare UPIN
TN103I974027Medicare PIN
TN103I975882Medicare PIN
TN103I975883Medicare PIN
TN103I975881Medicare PIN
NOPA14531Medicare ID - Type Unspecified