Provider Demographics
NPI:1144636838
Name:NOWAK, ALLIE RAE (PA-C)
Entity type:Individual
Prefix:
First Name:ALLIE
Middle Name:RAE
Last Name:NOWAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALLIE
Other - Middle Name:RAE
Other - Last Name:JAGIELO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5125 NORWOOD LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2069
Mailing Address - Country:US
Mailing Address - Phone:715-630-5392
Mailing Address - Fax:
Practice Address - Street 1:4100 REDWOOD RD # 20A-616
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-2363
Practice Address - Country:US
Practice Address - Phone:510-849-6500
Practice Address - Fax:510-849-6501
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59272363A00000X
363A00000X
MN11649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant