Provider Demographics
NPI:1396718144
Name:NOVOSAD, CALLIE (PA)
Entity type:Individual
Prefix:MS
First Name:CALLIE
Middle Name:
Last Name:NOVOSAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PLEASANT VALLEY DR
Mailing Address - Street 2:STE 210
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5683
Mailing Address - Country:US
Mailing Address - Phone:830-267-4575
Mailing Address - Fax:
Practice Address - Street 1:15102 JONES MALTSBERGER ROAD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247
Practice Address - Country:US
Practice Address - Phone:210-745-0084
Practice Address - Fax:210-745-0139
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096725225100000X
TXPA05399363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208326303Medicaid
TX8L4209Medicare PIN