Provider Demographics
NPI:1730132010
Name:NOVAK, VICKI LYNN (PA)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:NOVAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:L
Other - Last Name:WINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:500 VONDERBURG DR STE 311W
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5978
Mailing Address - Country:US
Mailing Address - Phone:813-654-2445
Mailing Address - Fax:813-954-9885
Practice Address - Street 1:500 VONDERBURG DR STE 311W
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5978
Practice Address - Country:US
Practice Address - Phone:813-654-2445
Practice Address - Fax:813-954-9885
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116644363AM0700X
IA2211363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ021430001Medicaid
AZQ65029Medicare UPIN
AZQ65029Medicare UPIN