Basic Information
| Provider Information | |||||||||
| NPI: | 1144405580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOVAK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WHEELER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP-PMH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1978 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218021978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491015 | ||||||||
| FaxNumber: | 4107490654 | ||||||||
| Practice Location | |||||||||
| Address1: | 12145 ELM ST | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218531358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106512204 | ||||||||
| FaxNumber: | 4106510790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2008 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R119086 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 0024168080 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 119591300 | 05 | MD | MEDICAID |