Provider Demographics
NPI:1427440213
Name:MARK A. NOWACKI MD PA
Entity type:Organization
Organization Name:MARK A. NOWACKI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:NOWACKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-347-4158
Mailing Address - Street 1:7011 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1203
Mailing Address - Country:US
Mailing Address - Phone:727-347-4158
Mailing Address - Fax:727-345-2260
Practice Address - Street 1:7011 1ST AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1203
Practice Address - Country:US
Practice Address - Phone:727-347-4158
Practice Address - Fax:727-345-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60591305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372504900Medicaid
FL372504900Medicaid