Basic Information
| Provider Information | |||||||||
| NPI: | 1407940497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOWACK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | VICTOR | ||||||||
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| Credential: | D.P.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3482 | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838773482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082096170 | ||||||||
| FaxNumber: | 2082096169 | ||||||||
| Practice Location | |||||||||
| Address1: | 6186 W MAINE | ||||||||
| Address2: | |||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086236717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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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 | 225100000X | PT00009579 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8446924 | 05 | WA | MEDICAID | 0201431 | 01 | WA | LABOR AND INDUSTRIES | OTHER |