Basic Information
| Provider Information | |||||||||
| NPI: | 1811991359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOWAK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1932 ALCOA HWY | ||||||||
| Address2: | STE 270 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652514658 | ||||||||
| FaxNumber: | 8652514659 | ||||||||
| Practice Location | |||||||||
| Address1: | 1932 ALCOA HWY STE 270 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652514658 | ||||||||
| FaxNumber: | 8652514659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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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 | 363A00000X | 10410 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 1692 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 3305 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID | 41984300 | 05 | WI | MEDICAID |