Healthcare Provider Details

I. General information

NPI: 1972546596
Provider Name (Legal Business Name): JAYNE L NOVOTNY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRE SD
57501
US

IV. Provider business mailing address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRE SD
57501
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-7070
  • Fax: 605-224-2514
Mailing address:
  • Phone: 605-224-7070
  • Fax: 605-224-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number417
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0417
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: