Provider Demographics
NPI:1447028774
Name:NOVAK, NATHANIEL R
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:R
Last Name:NOVAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 455 BOX 208
Mailing Address - Street 2:MULTI-SERVICE UNIT DEPARTMENT
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96540
Mailing Address - Country:US
Mailing Address - Phone:671-344-9208
Mailing Address - Fax:
Practice Address - Street 1:FARENHOLT AVE
Practice Address - Street 2:BUILDING #50
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-344-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5095364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology