Basic Information
| Provider Information | |||||||||
| NPI: | 1750328563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOVAK | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322874 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/23/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 8935 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 121640 | 01 | MN | UCARE # | OTHER | 1750328563 | 05 | MN | MEDICAID | 73A13NO | 01 | MN | MNBS # | OTHER | DA9041015688 | 01 | MN | PREFERRED ONE # | OTHER | 0121199 | 01 | MN | MEDICA # | OTHER | 73A11NO | 01 | MN | MNBS # | OTHER | 18231 | 01 | MN | NDBS # | OTHER | HP25821 | 01 | MN | HEALTHPARTNERS # | OTHER | 0111296 | 01 | MN | MEDICA # | OTHER | 0111297 | 01 | MN | MEDICA # | OTHER | 022387500 | 05 | MN | MEDICAID | 975261 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER |