Provider Demographics
NPI:1538781372
Name:NOVICK, JACOB ADAM (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ADAM
Last Name:NOVICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 STONEBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-5457
Mailing Address - Country:US
Mailing Address - Phone:916-300-5437
Mailing Address - Fax:
Practice Address - Street 1:1346 STONEBRIDGE WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-5457
Practice Address - Country:US
Practice Address - Phone:916-300-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant