Healthcare Provider Details

I. General information

NPI: 1972937837
Provider Name (Legal Business Name): AVA M NOVOTNY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39350 CIVIC CENTER DR SUITE # 300
FREMONT CA
94538-2331
US

IV. Provider business mailing address

39350 CIVIC CENTER DR SUITE # 300
FREMONT CA
94538-2331
US

V. Phone/Fax

Practice location:
  • Phone: 228-762-4483
  • Fax: 228-769-0406
Mailing address:
  • Phone: 510-797-3933
  • Fax: 510-797-5184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: