Provider Demographics
NPI:1588153514
Name:NOWAKOWSKI, DAVID (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:NOWAKOWSKI
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:DAVID NOWAKOWSKI, CRNA
Mailing Address - Street 2:225 S EXECUTIVE DRIVE
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-4050
Mailing Address - Fax:262-439-7683
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-433-0111
Practice Address - Fax:920-431-3082
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI241707-30367500000X
WI8450367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100079019Medicaid