Provider Demographics
NPI:1942594338
Name:NOVAK, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NOVAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:HERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-754-5036
Practice Address - Fax:616-754-4380
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32930402Medicare PIN