Healthcare Provider Details

I. General information

NPI: 1942594338
Provider Name (Legal Business Name): AMANDA NOVAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA HERD PA-C

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

5555 GLENWOOD HILLS PKWY SE STE 2
GRAND RAPIDS MI
49512-2091
US

V. Phone/Fax

Practice location:
  • Phone: 616-754-5036
  • Fax: 616-754-4380
Mailing address:
  • Phone: 616-940-2662
  • Fax: 616-685-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: