Provider Demographics
NPI:1902314180
Name:NOVAK, ALICIA E
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:E
Last Name:NOVAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 S RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1014
Mailing Address - Country:US
Mailing Address - Phone:570-552-7170
Mailing Address - Fax:570-552-7169
Practice Address - Street 1:672 S RIVER ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1014
Practice Address - Country:US
Practice Address - Phone:570-552-7170
Practice Address - Fax:570-552-7169
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017816363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP017816Medicaid