Healthcare Provider Details

I. General information

NPI: 1255659025
Provider Name (Legal Business Name): ERIC NOWAKOWSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 02/01/2022
Certification Date: 02/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 N PIEDRAS ST
EL PASO TX
79920-5001
US

IV. Provider business mailing address

1910 SOUTH RD
POUGHKEEPSIE NY
12601-6053
US

V. Phone/Fax

Practice location:
  • Phone: 915-569-2121
  • Fax: 915-569-1233
Mailing address:
  • Phone: 184-545-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013694
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: